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Waste Tire S*vey & Inspection Reporo Inspection Report Number <br /> Cal Recycle State of California I 1 - 1176428 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- ` ,t* _ Inspection Type(Fill one) <br /> Site Suffix: (Tr'•"� / ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -Tpq 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> C �C �ir\� f1.lC try <br /> Physical Address V 3 t <br /> J Inspection Date <br /> L,d. CjA q 5.2`42 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> iZ 3 0 PM .Z ® 0 PM <br /> V,•>ce, Lu + Flo v - <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 /> ` 30 0 Active 0 Passenger 0 Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use <br /> Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 [E FORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- -- ---- ---- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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 /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> 0 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 � /* <br /> j�lkC Inr�kp� <br /> Inspection Form Included: 0 /7 <br /> Comments Included: ® Wlx�zl �v-�� C L'> ����� 3 <br /> Business Rep's Signatu Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [IDorreCt.'4Incorrect: EXAM E 1 213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />