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0 Waste Tire ey & Inspection Repolpinspection Report Number <br /> CalRecycle State of California 11 - 1245334 <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- � � � p � � _ Q � Inspection Type(Fill one) <br /> Site Suffix: O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /1 If Referral,choose referral type(Fill one) <br /> Identifier. O CHP 0 CalRecycle o Complaint 0 Educational Visit 0 Other <br /> Bu�ess or acility Name � !� � Inspected By Inspector <br /> 0 Physical Address <br /> Inspection Date / j / <br /> Time In Time Out <br /> Business Rep Title0 AM z0 AM <br /> (� 1 Z- <br /> . • 46 PM 1 d 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 /> 40 Active 0 Passenger I* Generator 0 O�utdp�r <br /> O 0 Closed 0 Altered %1,`/_ <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 41 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Coimpliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O1 Other:§ <br /> �, ._.p � +-� 4*.1� <br /> Comments (� �� �3c.�'� u-�.sC � r�a�1.IJX.st:.C.f�C.� p�-�yu O'-L GL� N <br /> Cy CkLQA 0 CCS <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> B ess Rep's SignattTre Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON ACK Correct: Incorrect: M w EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />