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03 Waste Tire Avey & Inspection Repor ., Inspection Report Number <br /> CalRecycle State of California 11 - 1255909 <br /> CalRecycle 181(Rev. (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- I �. 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: Ut Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T4 (::-, <br /> Physical Address <br /> 17 <br /> V�c C -77:� Inspection Date l S <br /> Time In Time Out <br /> Business Rep Title ,` AM AM <br /> ra l ftjfaG ✓ <br /> ' � ''ll Z �j (t> 0 P �' � D 0PM <br /> GtY I -, 1/i�tW <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 /> 9 Active ® Passenger &Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ! Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 <br /> 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 EXE N <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 /> 2 <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 /> Comments�r,.L�.-1��� (.�l:Q/�tF �FC.�- 1Y1,,.:L�� �Chtk� Z,V1.�'► t,rtD �%� N <br /> i r�l C� k'i✓J C r �Zcr� f�k�9 i- <br /> Inspection Form Included: Q / t 4ty0'7� <br /> Comments Included. ® C <br /> Business Rep's Signature Phone Nu er Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X 1� IEIXIAIMIPILIEI 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />