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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242169 <br /> CalRecycle 181(Rev. (Ca[ 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: j ( 1, ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: _S( t_A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �� UU Inspected By Inspector <br /> i.��rY'�S ✓1dfzx'cc�c. eslzti,�v� 671 <br /> Physid ll Address — <br /> 1s! <br /> Inspection Date _7 <br /> Time In Time Out l <br /> Business Rep Title 0 AM 0 AM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ) ] (Fill one only) (Fill all that apply) (FII all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 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 Dismantier 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 10 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 010 1 Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: Q WJ <br /> Comments Included: ® C ��—� � <br /> Bus Hess Rep's Signat Phone Number I'n p tor's gn Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JEXjAjMPjLKj1 2 3 szosi <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />