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Waste Tire Sui vey & Inspection Report nspection Report Number <br /> Cal Recycle State of California I 1 - 121016 8 <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- Inspection Inspection Type(Fill one) <br /> Site Suffix: C) ` `Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0. V`� � -../ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name , Inspected By Inspector <br /> Physical Address <br /> 60 k V\ <br /> ��]]CCInspection Date 7 / <br /> / 3 <br /> �� G�G�0V\ I72! <br /> Time In Time Out <br /> Business Rep Title 0 AM0 AM <br /> Crn PM c 0 PM <br /> .e.� "l <br /> Ma 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 Q Ou'dpor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ! OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 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 <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 /> PRC§42956-Registration/Decal in Vehicle 7 <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 0 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 is In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> oc �.Cel!tq v.cQ C <br /> Inspection Form Included: <br /> Comments Included: ow <br /> Business Rep's gnature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correc . Incorrect: IEIXIAIMIPILIEI 1112N 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />