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Waste Tire Survey & Inspection Rep® . Inspection Report Number <br /> CalRecycle State of California 11 - 1245318 <br /> CalRecycle 181(Rev.y(Cal 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- Q / Inspection Type(Fill one) <br /> Site suffix: / O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ;j1 �Q� U/Yj Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Bu27;or Facility Name Inspected By Inspector <br /> Physical Address 3 0 <br /> cC11— `7j_3o Inspection Date / z / t <br /> �f� <br /> Time In Time Out <br /> Business Rep Title ( 0 AM /� 0 AM <br /> -V � { / ® PM f V QPM <br /> rY,,'�• �Yre i c - '-5 Operational Status Tire Type Business Role Storage Type <br /> r <br /> Tire Count h e/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 <br /> • Active 0 Passenger a Generator Q Outdoor <br /> O Q Closed � Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer s 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 I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> Comments �� �,yfl� ���ir l�-C.x l 1'�-�:Q-Cr_1 �JfZ �y�-� � ��" �'�'`�� GJ� QZp•� N <br /> ( Q c,✓ C <br /> Inspection Form Included: 20y <br /> '*a- <br /> Comments Included: <br /> B ess Rep's Signa ure Phone Number Inspe <br /> ' ctors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: 0 EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />