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Waste Tire Sur vey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California I 1 - 1210115 <br /> CalRecycle 181(Rev. (Co) 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- ` _ 0 Inspection Type(Fill one) <br /> Site Suffix: Ob Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �l i l If Referral,choose referral type(Fill one) <br /> Identifier: Qn J oc�l w f\ (tAnt 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P11a _+1 V;; ;vn 3 - ( <br /> Physical Address v j� <br /> I C--C(-OTTD <br /> C . mjkr� S <br /> S�oCA �52oS I\\-- Inspection Date Q � 10 3 <br /> v�L�'Dri <br /> Time In Time Out <br /> Business Rep Titler� U ®O AM 1 1 0 AM <br /> ' ' � PM �( ® 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 /> 0 Active 0 Passen er 0 GeLn�e'rator 0 Outdoor <br /> O 0 Closed 0 Alte�,7A r te/ NJ <br /> GPS Latitude 0 Hauler 0 IndodrA <br /> 0 0 Inactive 0 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 /> Q Notice Of Violation Q 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 a <br /> (Required for NOV or EXTJ <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 /> Q O Other:§ <br /> Comments <br /> No V;44i'vn S 61 cesm3C os11 <br /> 6o cu� ik ji . N �,A'Sa,., L 6 b - ds PrD <br /> Ij <br /> Inspection Form Included: 0 <br /> Comments Included: Q �� V — - -A( -3 <br /> )79 <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: E X A M L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © ■ <br />