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02 Waste Tire St-. ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1176757 <br /> CalRecycle 181(Rev. (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- 11 Inspection Type(Fill one) <br /> Site Suffix: 3 of l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V` �u(�C�t/1� �lt, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name li (( Inspected By Inspector <br /> ) <br /> Physical Address - Q �✓n�(c,, <br /> Inspection Date <br /> Time In Time Out l <br /> Business Rep Title // AM ®AM <br /> 1 V b O PM l O I O 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 /> Q Active Q Passenger Generator Q Outdoor <br /> Al ge <br /> 1A <br /> 0 a Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude -- .-- -- Q OTR Q End-Use Q ContainerQ Planned <br /> - — - -- -- - - <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 CalRecycleLo <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <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 /> Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments � �j I�*;Icy -s l' In ,� i+ <br /> +( � �y�L l�.r� UC <br /> �Y S I ✓[5 .® Z�G_� �t� 'C`/1 r —s;.l_l-.�C� J.�G�C <br /> 1 1,h J c � <br /> CW <br /> Inspection Form Included: Q <br /> Comments Included: Q Business Rep's Signature -Phone Number In.lCop : <br /> s ur Phone NumbeINSTRUCTIONS ON BACK Correct: Incorrect: ( 62081 <br /> X6 JE) >� 123I■ White Copy:CalRecycle Yellow Copy:Operator Pi �� ■ <br />