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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1210358 <br /> CalRecycle 181(Rev. (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- I � � � � � O � Inspection Type(Fill one) <br /> Site Suffix: * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 � o\ C9Vh 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physicbl Address ` 39 d 1 M AI'T v <br /> Inspection Date ( C) 3 / 1 3 <br /> V / <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> ` > *PM 2 0 PM <br /> CV C��S 50.60 n 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 0 Generator 0 Outdoor <br /> O 4j Closed 0 Altered t /A x1 <br /> GPS Latitude NIA 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 /> Q Notice Of Violation Q Extension <br /> 0 0 <br /> 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 /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 or EXE n <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 /> 2 <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 J@ In Compliance-No Violations o <br /> O O Other:§ <br /> Comments1, Ift <br /> anted pn S'. �swd�- e A�rpS r�elc :No tibtax� <br /> Ov%S or/r/� <br /> �k <br /> �� eS' 11 04 abbe 13,...,�y �xaCtiSS c-� o cad its \oca\:`on <br /> Q- <br /> � <br /> Inspection Form Included: 0 y 5o u <br /> Comments Included: Q %' ��Z�c`�lb�-3�$ -1 <br /> I ess Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ACK Correct: Incorrect: jEjXjAjMjPjLjEj 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />