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Waste Tire Survey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245310 <br /> CalRecycle 181(Rev.y Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) - <br /> 3art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: "� I 1\ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localc l If Referral,choose referral type(Fill one) <br /> Identifier: 1 J� I n C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected By Inspector <br /> Physical Address <br /> Inspection Date / I <br /> f Time In Time Out <br /> Business Rep Title fO AM O AM <br /> h f Q d PM S • PM <br /> ��'---Aperational Status Tire Type Business Role Storage Type <br /> Tire Counth le/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply),kl <br /> & 0 Active Q Passenger ®'Generator 41)Outdoor �? <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 46Indoor <br /> O Q Inactive ® 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 10 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 /> Q Q 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 CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 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 /> W <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 *n Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments /_71'7 T A, /l <br /> dU� V i d 1_&b�,t,�- a� r �Q <br /> Inspection Form Included: Q J Z� <br /> zo rl y �. <br /> Comments Included: <br /> O ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P LEI 1 2 1 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br /> 1 <br />