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Waste Tire Sugey & Inspection Repo rtolnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242509 <br /> CalRecycle 181(Rev.y(Cal Survey Form age <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Y 3 c q © i Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localc , If Referral,choose referral type(Fill one) <br /> Identifier: �7r^ v <br /> n 0klt, Cavinfil�l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> --` Inspected By Inspector <br /> -`)S �Z_ us <br /> Physical Address CScUT T� <br /> Inspection DateU <br /> Time In � / Time Out / <br /> Business Rep Title ® AM I (� ®AM <br /> V 1C1�Or l�C" let.C �G. O -3o Q PM / V O PM <br /> Gln r_ <br /> Operatlonal Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger ® Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0- 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> 1 <br /> Comments <br /> �,f 5 1 �L- - -- <br /> N Vit01 AI1' of c4f w _�_coj)Wn� <br /> Inspection Form Included: O <br /> Comments Included: COQ <br /> Busin ss ep's Signature Phone Number Inspe is Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: XOV� 1 E I X I A 1 1112131 <br /> 62081` <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />