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Waste Tire Su. ,rey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle ( <br /> I 1 - 1210192 <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- Q Inspection Type(Fill one) <br /> Site Suffix: / Z 3 '1 '9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: vr�`n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T Inspected By Inspector <br /> Physical Address <br /> ��C� Inspection Date -7 / 'L <br /> %3*30 <br /> Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> p a' L O 0P , 40PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' J 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Is Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years LO <br /> Q O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> ` - z <br /> Comments )i Cct sY _ PA=C C�J�>2 rsx"' <br /> Inspection Form Included: Q ��� <br /> Comments Included: • <br /> Business ep's Signature hone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />