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Waste Tire Su vey & Inspection ReportS,lnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242067 <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: l -6 : 14 Q 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: SCOA el_ov-rl Lf0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> �Vl 1` \� � I Inspected By— Inspector <br /> Physical4A dr�s P0_ ei 1L.l�Yv� —� 9 C G /�r\{� " 6l✓� <br /> L P \ / 1 <br /> ( } Q Inspection Date <br /> Time In Time Out 1 <br /> Business Rep Title AM 0 AM <br /> k `�7 : ® 5— ` PM � � � 3" ® 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 /> 0 Active 0 Passenger Q Generator 0 Outdoor <br /> O � <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler ® Indoor <br /> O 0 Inactive Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> I <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair • 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 <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 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orEXn N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 " " 5) qq <br /> B <br /> ssRep's Signature Phone Number j?s7ecf90W9naVdre Phone Number <br /> - �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � NJ E X M 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop�L <br />