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Waste Tire amu'Vey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California 1 1 - 1245092 <br /> CalRecycle 181(Rev. (Cal 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- / /�, b Inspection Type(Fill one) <br /> Site Suffix: �V —` 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: u t 001-0 h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Busin s or Facility Name Inspected By Inspector <br /> Physical Address ✓ 1 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title jL O AM O AM <br /> do PM 10 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active o Passenger &Generator ® Outdoor <br /> Q Closed Q Altered <br /> GP� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 40 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 I A I 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 /> Q Q 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 EJCT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> g <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> o �CIWZ Oy- aA1c� Z)-(L- y -S <br /> Inspection Form Included: Q �k citG t' P I/` <br /> Comments Included: 'Oh 6 <br /> Business Rep's Signature Phone Number Inspector' ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X741 g E I X I A I M I P I L I E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />