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Waste Tire Sulk vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1242416 <br /> CalRecycle 181(Rev.y(Cal[cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery Recycle) <br /> Part A-Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 9 "f Q 'g -7 rj ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: &V\. �.)Qf ��, �OWV�1�/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U00 ((( Inspected By Inspector <br /> hy '1lcalddreJsC-I i �e- - l o /`��lzli�(,s--/� <br /> Inspection Date �.7 / / �-� / r <br /> J � ✓� CSI q <br /> Time In Time Out <br /> Business Rep Title ® AM `` AM <br /> 1 © S 5 O PM � l (� 0O PM <br /> Z-0--s2 ® � <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 77 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 /> 0 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 /> Q Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> a <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> Inspection Form Included: 0 �L [ Ot - <br /> Comments Included: <br /> B ess Rep's Si j2to Phone Number In p ctor' n ure Phone Number <br /> Of 4 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � E X A M P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />