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Waste Tire Su, vey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1230181 <br /> CalRecycle 181(Rev. (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- ` _7Inspection Type(Fill one) <br /> Site Suffix: b 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CW v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> G`val Cow•W)ecc w\ 3 9 1 d M Ty <br /> Physical Address - <br /> S ^` CA- S inspection Date <br /> 1 Time In Time Out <br /> Business Rep / Title ` t O AM 1 2 C 0 AM <br /> U-OV��Cs�2 �j I,t�LQ'�. '(' 0 PM �.J ® 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 /> &Active 0 Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 9 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other � {\C,e,S2(`V t '<04� <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 / m / 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments GLS (" v\ <br /> V:C_A(�,�or tA. <br /> Inspection Form Included: Q ' r _-5 <br /> Comments Included: - — - -24tl2 4 <br /> ep <br /> siness R 's Signa re Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X V EXAMPLEj 1112L3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />