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Waste Tire Survey & Inspecti®n Report inspection Report Number <br /> State of California <br /> CalRecycle 11 - 12 4 4 9 2 <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- Inspection-� C l 0 O / Inspection Type(Fill one) <br /> Site Suffix: 1 J l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ,A If Referral,choose referral type(Fill one) <br /> Identifier: —)d--O�C u q lAt i^ Chun 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �! Inspected By Inspector <br /> Physical Address <br /> ES UOST(� <br /> Inspection Date <br /> Time In Time Out <br /> Business `Rep / Title Q AM /� S Q AM <br /> \ A`rL l'�1�L�SLS C 1AtQ m E, 0 PM J • ' `-+ ® PM <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 /> S * Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other G-,)r fej'6 ( �nj\4 "JQT <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) A <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> — z <br /> Comments n L ' <br /> - -2-(��Ak�'� LA�/t •� (u �r)5 tbti 67,4113 <br /> -- N o V�o�, �,s resta cioncy-in- <br /> Inspection Form Included: 0 <br /> A<2ni) <br /> Comments Included: ® <br /> usiness 's Signature Phone Number Inspec 's Signature Won Num er <br /> INSTRUCTItIS N BACK =Correct: Incorrect: EXAM I P 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />