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Waste TirL ..drvey & Inspection Rei.... Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245190 <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- Inspection 1� � � U � Inspection Type(Fill one) <br /> Site Suffix: (� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � V�r� CCC1 0_..� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . <br /> Inspected By Inspector <br /> kc-LL,,�II�k �cpas'sCo Jxlb.. <br /> Physical Address U �� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM AM <br /> 2- ' ® PM �' 4 PM <br /> ���, ��ck��., Adt'kt n . Ams; <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count 9he/PTE) <br /> Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Sc Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill ail that apply) <br /> Q New Tire Dealer Q Auto Repair O 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 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 EXr7 <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 /> 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 /> CommentsJab ap- j :A4 <br /> , <br /> Inspection Form Included: Q I —7 <br /> Comments Included: � <br /> usiness Rep's Signature Phone Num nspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK �Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />