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Waste Tire Su.vey & Inspection Repon -Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1244901 <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- 0 p Q 1� Inspection Type(Fill one) <br /> Site Suffix: l 1� Routine Q Re-inspection Q Referral Q Observation <br /> Local �"(' If Referral,choose referral type(Fill one) <br /> Identifier: gso r) VO��•\f1 ��,���1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v <br /> Inspected By Inspector <br /> MLO ffIAJ <br /> Physical Address - 1 ' CS co TQ <br /> ���� Inspection Date � / � g <br /> CA IS-Lo 6 Time In Time Out <br /> Business Rep Title c O AM O AM <br /> C I S � 'Cq_ ® PM � � QPM <br /> � � , r+ �St� Operational Status Tire Type Business Role Storage Type <br /> 3 c (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) J <br /> .® Active 49 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive IV Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® 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 K)Jdll "diol <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 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 /> 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 /> 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 e In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments Z4�1_c <br /> O u s R 48'- <br /> +No cos Ul1e�,lS �x�nrern <br /> Inspection Form Included: <br /> Comments Included: <br /> Busi Rep's Signature Phone Number Insp c or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: M � E X A Na P 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co i :LEA <br />