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Waste Tire Sw ✓ey & Inspection Repor L Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210437 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` _` lo Q Routine Q Re-inspection ® Referral Q Observation <br /> Local �— 1 If Referral,choose referral type(Fill one) <br /> Identifier: J��� Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Bushiness or Facility Name <br /> R' I L Inspected By Inspector <br /> �ress 0- l /'� <br /> Physical�d � CS C0v-0 <br /> CA <br /> Inspection Date 7 / Q <br /> Time In Time <br /> a Out <br /> Business Rep <br /> �� ` rr 1� J Title M � M��. ) Q 0 PM `9 AM v 0 PM <br /> r)� �Su� l OPS _ AJC. <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 Q Generator Q Outdoor <br /> O • Closed Q AlfeTe/A r" f N <br /> GPS Latitude Q Haul <br /> ef Q Indoor <br /> 0 Q Inactive Q 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 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 J>/1 <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 <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 EXTJ 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 /> 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 <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> L ,jam z <br /> Comments � � i ( �P ' f� ��)0 (1rCll�iC Tno . N <br /> � Z y el' b- <br /> Inspection Form Included: Q �, <br /> Comments Included: Q <br /> usi ss ep's Signat Phone Number Inst ctor's Signature _Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � n ae E X A P L 1 2 1 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : A �� ■ <br />