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Waste Tire St.,vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177973 <br /> CalRecycle 181(Rev. (CaI 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 � � © � Inspection Type(Fill one) <br /> Site Suffix: lQ ✓ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n� �jA C'Uf (,(i��' Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �E�o(- C)�L <br /> Physical Address l CS(0 )l <br /> a�a o mit 0 . v <br /> Inspection Date 7 / 1 3 / 1 <br /> Time In Time Out <br /> Business Rep Title r 0 AM 7 Q AM <br /> J ® PM J ® 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) (FII all that apply) <br /> ' ' Q Active ® Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ® 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 ® 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 ® 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) N <br /> r <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 /> 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 <br /> in Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments -L i `�Nlt (AWf ^ F�a' Qbl,��n <br /> to 1)061 <br /> Inspection Form Included: Q �WjAXXy I WV% <br /> Comments Included. �v 7 <br /> Business Rep's Signature Phone Number Inspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: zsC � E X AMP L jE <br /> op1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cy ® ■ <br />