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Waste Tire Avey & Inspection Repoi . Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245353 <br /> CalRecycle 181(Rev. Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type(Fill one) <br /> ®Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: A)Gt—q 1tri �'�K 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `dl V Inspected By Inspector <br /> 1 12X <br /> VI,,SoYl L�j 1 C <br /> Physical Address <br /> �I <br /> 14 OQ z _ P-esca dov A-z= . <br /> Inspection Date ct / 1 <br /> Time In Time Out <br /> Business Rep TitleI Q ®AM j 7 2 O AM <br /> SCaf� O PM SPM <br /> Operational Status Tire Type .Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger & Generator 0 Outdoor <br /> O 0 Closed 0 Altered h(A—, <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> v <br /> 0 & 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments V ack.4� � �k/J ( d <br /> Inspection Form Included: 0 a0� / <br /> Comments Included: . <br /> Business Rep's Signature Phone Number Inspector's Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />