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Waste Tire SL.,vey & Inspection Report nspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 Il 1196414 <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 Inspection Type(Fill one) <br /> Site Suffix: Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �- , If Referral,choose referral type(Fill one) <br /> Identifier: �f� 30a, , )n CQ CHP Q CalRecycle0 Complaint Q E <br /> ducational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 6� a aS ,�, <br /> Physical Address ESCA�� Q <br /> S�U � C1<,LOS Inspection Date (D a 9 <br /> Time In Time Out <br /> Business Rep Title 5 10 AM CAM <br /> O PM V Q 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 Q Passenger Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler ® Indoor <br /> O Q Inactive ® 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 O Other QLtS F <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EX ) 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 /> 2 <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 1 Q 1 Other:§ <br /> Comments ��l'�- lJ��`j�>✓ \1 !,� �nSQP 'can ,l)-�.-�--ti��f� �Jll��`�-0.._ b �r' �, <br /> i a 1 �tr�5 6 S �� 1e[..S I 1--,r)(er C� <br /> Inspection Form Included: Q <br /> Comments Included: ® - <br /> Business Rep's Signature Phone Number Insp c or's Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P El 11J2131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy LEA ® ■ <br />