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2 Waste Tire S_ _ vey & Inspection Repor Inspection Report Number <br /> CalRecycle State of California 11 - 1230435 <br /> CalRecycle 181(Rev.y(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- Inspection Type(Fill one) <br /> Site Suffix: ' c j 41 CA' S ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier: <br /> SCA,; �' �� �r a 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address L <br /> tdrj)Zi,:�,Z1Uj- <br /> Inspection Date / G / � D <br /> 4 Time In ` Time Out L <br /> Business Rep Title r AM (a AM <br /> r <br /> ?''VIS ® PM r �� 5, ® PM <br /> e to"%�1j P 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 ® Passenger Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered d/ <br /> GPS ' ` <br /> 0 Hauler 0 Indoor <br /> O Q Inactive Q 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 ® 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 <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business heep's Signature Phone Number Os7ect is S' na re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X I A M L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin Cop :L © ■ <br />