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0 Waste Tire Sui vey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California I 1 - 1242051 <br /> CalRecycle 181(Rev.y(Cal Survey Form — Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V G I] <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 7 _ O Inspection Type(Fill one) <br /> Site Suffix: ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 5�h 76 <br /> c q %'V �V O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `` Inspected By Inspector <br /> Physical Address <br /> 12 3S crl' S� I <br /> Inspection Date <br /> Loc . C� °fSZyd <br /> Time In Time Out <br /> Business Rep Title 1 1 0 AM O AM <br /> J Q PM L J 0 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> o lb Closed Q Alter <br /> GPS Latitude O �� 01 <br /> Longitude o OInactive O Truc � Q� X <br /> Q Planned O OTR O End-Use <br /> 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 /> 0 Notice Of Violation Q Extension <br /> O O 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 /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 1 O 1 Other:§ <br /> Comments <br /> ���1-a,�►7�, ��aTZ`'�e.b.��� �ic� \vr�S1�eC�piLl �,r,�r•�._—�n� �t O.n.�. <br /> CSA5 <br /> ��-����U`�'�,nc�� � ��, \�•rcr ►� `'�1n.5 \dc��l.�n �.w �iS.,r>es� <br /> C. <br /> , ce. M&\w ( l 4l <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> �1-Y6$3Zg <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: :X:4:9:fl* Incorrect: E .X A M P L E 1 2 3 s2os1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />