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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210242 <br /> CalRecycle 181(Rev.y(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: 1 0 tj y O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � � ` If Referral,choose referral type(Fill one) <br /> Identifier: _>i�t,V\ _JG( �hv✓t/ Q CHP Q CalRecycle Q Complaint -Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Iry-, z' Lonvr,✓firn c <br /> Physical A�_dress <br /> Inspection Date <br /> C4 Qda p Ci L <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> '*NC�V,'rrAL � L O O PM l b �f (J O PM <br /> NI �h Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4P ® Active Q Passenger ® 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 EXT) <br /> r <br /> a <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 1 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 ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments ��^^ <br /> Inspection Form Included: `Y A?IZ6 3 <br /> Comments Included: ® VI _1 J <br /> BSignatur Phone Number 1 p tor' S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E X A E 11213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C y: A ® ■ <br />