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0 Waste Tire SAey & Inspection Reporolnspection Report Number <br /> CalRecycle State of California81( I1 - 1230254 <br /> CalRecycle 181(Rev.y(Ca) 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- CD ` Inspection Type(Fill one) <br /> Site Suffix: `1 G 1 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v` Coo 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name \' Inspected By Inspector T <br /> Phy al �s C� 3 C� - y Q M 1 <br /> Inspection Date 1 -7 / I 2 / ' 11 <br /> E s c4oY, C is32o <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> c C 1 • O S .0 PM ' • 3 #PM <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 /> IS Active 0 Passenger * Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 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 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 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 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 EXE N <br /> a <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 <br /> In Compliance-No Violations o <br /> Q 0 Other§ <br /> Comments 1 DI/�_.�S1Ll� Gy, i S <br /> r N.� - p\ CL'shi <br /> Inspection Form Included: 0 _ Fog ` <br /> Comments Included: ✓����� `1l <br /> Bu ness ep's Signature Phone Number InspeckoPs Signature Phone Number <br /> _7*__]� � jjjjjj <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A M P L E 11 <br /> 1 2N 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />