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Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle I 1 ® 1177984 <br /> Cary lRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � _ � Inspection Type(Fill one) <br /> Site Suffix: 1 J ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��r'1 C <br /> 10 IA \ �7���� 0 CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Addre <br /> 0� A cam-�r u.c��. �u�5 a C�u � 3 q <br /> s <br /> d.S u feoW,) (fAf'rN?ftur I) <br /> Pl r t. C.-> www lll���lll <br /> �S�OLO Inspection Date <br /> Time In Time Out <br /> Business Rep Title \ l I D O PM 1 � � � � PM <br /> M AM <br /> N �u���i�.sa� ��S- 'rn�C - l 1 <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 /> Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ! Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Tr'Ac StA6 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / ITI / Ffl <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exp N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O Q Other:§ <br /> z <br /> Comments (� 1 \rte 1 <br /> AX\ ACxi m WU <br /> Inspection Form Included: O (� t-1 <br /> Comments Included: - !�?� / 41nspe <br /> Vor'sSignatZire <br /> v U— ) / <br /> B iness na re Phone Number Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: E X A M P L E 111213 620811 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cod. ® ■ <br />