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Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California( I 1 - 1177772 <br /> CalRecycle 181(Rev.y MO) Survey Form - Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I 7 __7 (� `� j 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local CC ,, �y��� If Referral,choose referral type(Fill one) <br /> Identifier: _ C'a \. `�"""-i>��1v1 1/11��J - Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> 4 G Y�wL (roti a <br /> Physical Address J Z - 1 1 n 0 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title AM / ® AM <br /> L (,J O PM I Q PM <br /> SEG <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 /> pL ® Active Q Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> a <br /> Q S 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 a <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Sce <br /> Cern N <br /> Inspection Form Included: <br /> ,rr 20,9_19931952- t y68 to Z5 <br /> Comments Included: <br /> Business Rep Signature Phone Number IF(SpehForls Ig ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: A ® 0 <br />