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------------- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1210573 <br /> ry <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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: I & 12- ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: ` A �"1 C0"VJ-L( Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f- / Inspected By Inspector <br /> Physical dd s� C..c.1/ C l��t/� LC✓(.&— - _ <br /> 1--FvtQ <br /> Inspection Date <br /> !V-CL cam., �1�53 ).�, U <br /> l Time In Time Out <br /> Business Rep Title ®AM 0 AM <br /> Acs c"Avyw'✓ s! 0 PM 1 5 ®PM <br /> 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 /> Q Active ® Passenger ®Generator ® Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m m N <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 EXE n <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 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 Q Other:§ <br /> z <br /> Comments <br /> fO 0 c4 <br /> w Jr>✓(c.?1r� c-r E V� �,)j z r t-X� Ala ht a � i V1 kJ �_ l� <br /> .3 �� ,�_ ✓lrr J �t,tmr?�t/ �t�,�tr`li-C�� �'1s� �G n ��3�Iy!r oe� <br /> d�3g3�� <br /> Inspection Form Included: Q <br /> Comments Included: – <br /> &S1ep s Signature Phone Number n ec or Signature Phone Number <br /> �,( 62081 <br /> * <br /> INSTRUCTIONS ON BACK [Correct. Incorrect: X NJ EXAMPLE 1 1112N <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />