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Waste Tire S.,..vey & Inspection Repor,, inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242311 <br /> CalRecycle 181(Rev.y(Cal 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- S © - O } Inspection Type(Fill one) <br /> Site Suffix: ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _.'C40 J O0, I I LA%n C�il� v� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FFaciilliity Name Inspected By Inspector <br /> �loeXt.� v n 01'e5P,� 3 q - 0 CS GU�O <br /> Physical Address <br /> Inspection Date � � 0 7 / I / <br /> Time In Time Out <br /> Business Rep Title Q 0 AM 0 AM <br /> ] <br /> l'1 r'rC` "1-� J 0 PM %PM <br /> � L,a�sfi�.�0 Cd- U�.JneJ' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) . <br /> (0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 41 Passenger ® Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <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 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 e Other pi r <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 ® 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 EXE 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 I*In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 1 C se"U'. /6"Na IMA rl �t� G1 <br /> �n�1191 n�i f� wcn,5 >n�� <br /> P.i �m MQ.�I1 R)Tr(N <br /> Inspection Form Included: ,nAl <br /> Comments Includ . r `"/ / v ZO `l 69-SOK <br /> Beep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin Cop : �� <br />