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Waste Tire Su. ,rey & Inspection Report nspection Report Number <br /> CalRecycle State of cle181(R I 1 - 1210331 <br /> CalRecycle 181(Rev.y(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- ' _ C) -7 ?_ 0l _ Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 0.,n J a �cp�g�,� CAQ\WA./ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address MA <br /> `A'Aoo V_P' N0b0c O�2 <br /> Inspection Date / 2 <br /> C o C_A X15 30 <br /> v1 <br /> Time In Time Out <br /> Business Rep Title Q &AM 0 AM <br /> 3 QPM ' D 0 PM <br /> v1C` v� �-owe�— S`r►o SV .GCv�Sc <br /> Operational Status Tin:Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator 10 Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> Notice Of Violation Q Extension <br /> Q Q 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 MO7 <br /> 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 EX ) <br /> 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 /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for WaMe Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ _ - <br /> Comments <br /> CK <br /> - <br /> Inspection Form Included: O Z� <br /> ® � <br /> � Comments Included: 3284 <br /> � - - <br /> qG?- <br /> Business� Rep's Signature Phone Number Ins ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X q�]jEjXjAjMjPjLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />