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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1230306 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> - 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- SInspection Type(Fill one) <br /> Site Suffix: J ) is Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 4.0 11-)L(L��r� /Wr uo1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �N,. n e. <br /> Ln- <br /> CA �s2us Inspection Date <br /> Time In Time Out <br /> Business Rep Title \ 0 AM <br /> n 0 AM U <br /> ��rf �n�� �O(i►L�� - V o PM t O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive • 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 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 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 /> 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 M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 G1 I fe P '1 l�-, (1Z� b� 5 Ll v'n <br /> �' V 10�► � � �! c� f���s 4Ct�1�La rn. <br /> Inspection Form Included: Qj r <br /> Comments Included:® - `ZQVon��V <br /> Busine Rep's Signature Phone Number Inspec s Signature <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM E10, 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CopX: A © ■ <br />