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2 Waste Tire ey & Inspection RepSonspection Report Number <br /> CalRecycle State of California I 1 — 1176490 <br /> CalRecycle 181(Rev.y(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- ` � rj Inspection Type(Fill one) <br /> Site Suffix: ` lQ D l '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: S n J urn Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Bu``ss\iinVness or FacilityName <br /> Inspected By Inspector/ <br /> Physical eI Cte s�' \CQ✓�. �7�M r4� _ l O In W� V <br /> 3 � <br /> / Q -0 Inspection Date <br /> Ck m 1 l J.y��b (� lel + 1 Ili <br /> Time In Time Out <br /> Business Rep Title 2 / 0 0 AM 0 AM <br /> t J v 9 PM S O . PM <br /> U n — " ej-V1 S,0r Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) u <br /> � ' 1 � Active Q Passenger 0 Generator A Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ! Truck <br /> Longitude — Q Planned ® 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 ® Other e� �5 <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 <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 EX7) 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 /> Lu <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 /> z <br /> Comments \ f� N <br /> Inspection Form Included: Q <br /> Comments Included: • ` <br /> usiness p's Signature Phone Number 4Inspectff' SignatureN Phone umber <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � E X A M L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: © ■ <br />