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Waste Tire S*ey & Inspection Repo A Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242538 <br /> CalRecycle 181(Rev. (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- 1 I l O Q Inspection Type(Fill one) <br /> Site Suffix: 1 e Routine Q Re-inspection Q Referral Q Observation <br /> Locall If Referral,choose referral type(Fill one) <br /> Identifier: Sac) J(0 !(A-�LA1� CUvtel 1 O CHP Q CalRecycle Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> DA CU Ae_ C r,-, Com.s� � <br /> Physical Address t 0 15 <br /> ✓r�� �!��� Inspection Date <br /> A J Time In Time Out 1 <br /> Business Rep Title O AM Q AM <br /> P-o6I_ I�516 5� 3, ' 1 0 • PM PM <br /> A �ufn5c� fjOA- mrnnu C/' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered ' J4 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR O End-Use Q Container <br /> Business Type(Fill all that apply) 1 <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 m <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (S Other C(�f)CIc�� 4nxf 4 AL4 - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance-No Violations o <br /> 1010 Other:§ l <br /> Comments n ]u 1 fe� i nspe'JlurN Oc�& hr-, +161, da_tZ Cen'O <br /> NON''6V1vAS aJ- GtIoc.5 0�"nCgrn <br /> Inspection Form Included: Q , <br /> Comments Included: `�O2`-yO �� `3 <br /> A ( <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA' <br />