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Waste Tire Su. ,✓ey & Inspection Report Inspection Report Number ■ <br /> CRI Recycle State of California I 1 - 1196554 <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- y t - O Inspection Type(Fill one) <br /> Site Suffix: 1 0 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0.Y\ 7_0 a-9 C �31'�/ 0CHP � CalRecycle 0 Complaint 0Educational Visit 0Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add ss <br /> 927 Vo\o_c ')%Q1MQYk Wa-y <br /> Inspection Date <br /> hod', C� °152"10 <br /> Time In Time Out <br /> Business Rep TitleC, O AM Z O AM <br /> u��w►tlf� CO,f I ✓ 0 PM / 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 I 40 Active 10 Passenger Generator Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude � Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned O OTR O 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 O 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 0 Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement g <br /> Lu <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> C� N <br /> Inspection Form Included: Q q�p//,Q_2'j Qr <br /> Comments Included: • l t_/'��.J�c� lo `GtX� Jt� <br /> Bus' ess Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X1� E X I A I M I P I L I E I 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />