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Waste Tire Sup dey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1210591 <br /> CalRecycle 181(Rev. (Ca[ 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- iInspection Type(Fill one) <br /> Site Suffix: l ,;;2 q `'y 12- f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C - If Referral,choose referral type(Fill one) <br /> Identifier: -�1�'1 .�' �E7 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Mme✓i c ,s Lmp,,(vl <br /> Physical Address 1 <br /> If ` Inspection Date —7 / <br /> may: CXR��Z� tr A <br /> Time In Time Out <br /> Business Rep Title O AM ` O AM <br /> 1 ® PM �1 ®PM <br /> YS vn� Operational Status Tin:Type Business Role Storage Type <br /> Tire Count Whole (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Ae ®Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 49 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® 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 /> 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 Q 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 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 CalRecycleIn <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) <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 <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: ® - <br /> Busl ess Re gna ure Phone Number nsect 's Ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E C I Al P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A <br />