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Waste Tire Sup Bey & Inspection Report nspection Report Number <br /> State of California <br /> CalRecycle 11 - 1196526 <br /> CalRecycle 181(Rev.y(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- 1 ^ � /��i O � -3 _ � , Inspection Type(Fill one) <br /> Site Suffix: / ` . Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: <br /> a� J d1 V�X"N CIDV�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 160A c,_ Q�- - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep ^� Title O AM O AM <br /> � r <br /> - QCv\ C\h Q.� 2 1 0 PM © ' 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 _ Q Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> (aPs Latitude Q Hauler Q Indoor <br /> O Q Inactive `Truck <br /> LaMptude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(FII 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 O ALAo Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Mauler Q Agriculture Q Shredder ® Other `��C�t..� � ,`e( sq�pt5 <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 <br /> Q Q 14 CCR§1845921 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> v <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 /> X <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 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 /> Comments <br /> o 'of Cl,)a_CPAS o - <br /> Inspection Form Included: Q ` /A <br /> N� q, Hd zoI,toe-3a 1 <br /> Comments Included: 5�y �' 7- <br /> Busi P's <br /> Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON B Correct:0 Incorrect: X q I(XIAIMIPILIE1 111273 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA . ® 0 <br />