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Waste Tire SiO✓ey & Inspection Repor, Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1226252 <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- nn Inspection Type(Fill one) <br /> Site Suffix: C9\ g & t @ Routine Q Re-inspection O Referral O Observation <br /> Local Z` If Referral,choose referral type(Fill one) <br /> Identifier. Ct V% �C t`_ ^�,,Lv►� WAV\ Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ti <br /> _ Inspected By Inspector <br /> L,��f5 � <br /> Physic�ddress 3 - O <br /> ?5��3 C timclo A-vt <br /> Inspection Date / �? G'Z / 1 Z <br /> Time In Time Out <br /> Business Rep Title _/� ✓ O AM Q AM <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 /> Q Active Q Passenger Generator Q Outdoor Outtdooor <br /> Latitude O@ Closed Q Altered A1111 <br /> GPS <br /> Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> LongitudeQ Planned Q OTR <br /> - Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture O 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 /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 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 orEX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 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 / <br /> A/Wy <br /> Ok C & I6-4 <br /> ,s► Y <br /> L ✓>°a fi ,s rlaca n1 <br /> Inspection Form Included: Q <br /> Comments Included: ® -,u e-pe&jz -- � <br /> -- - Business Rep's SignJn ture Phone Number 1'ns(6eZtor'sJ8i6ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( E A L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />