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Waste Tire 51L.. vey & Inspection Repor, - Inspection Report Number <br /> State of California <br /> CalRecycle I 1 .1245221 <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- CDr Inspection Type(Fill one) <br /> Site Suffix: I t _` ` 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local G+ If Referral,choose referral type(Fill one) <br /> Identifier: 7 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Bu 'Mess or Facility Name Inspected By Inspector <br /> j <br /> Physical Address <br /> CIS20 Inspection Date 0 �( / V <br /> Time In CJ Time Out <br /> Business Rep l Title i ( � 0 AM / O AM <br /> I I �✓ ' OPM �—' v ® PM <br /> five C ,-Y �p� <br /> 'Operational Status Tire Type Business Role Storage Type <br /> r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) v <br /> 0 Active Q Passenger 10 Generator ® Outdoor <br /> 0 Q Closed Q Altered ''!! <br /> GPS Latitude Q Hauler Indoor `'t' <br /> O Q Inactive ®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 /> 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 /> 6--U 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 EX ) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> lj�a& <br /> Ji y <br /> Inspection FormIncluded: y c <br /> Comments Included: ® ` , 7�K 2w; <br /> Bb s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: EJX�Aj 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />