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Waste Tire �*Vey <br /> & Inspection Re <br /> orAnspection Report Number <br /> State of California <br /> Resources CalRecycle 181(Rev. (Cal <br /> Dept.of Resoues Recycling and Recovery(CalRecycle) Survey Form - Page 1 11 - 1244913 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: CQ 5 I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J fir`�;�n ll1 n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ l <br /> Inspected By Inspector <br /> fill _T co.� 1'N o (VT a, <br /> Physical Address l GS COrT T <br /> 9 D-b W - 'S 1 <br /> r Inspection Date / O 3 1 C <br /> >3014 Time In Time Out <br /> Business Rep Title a O AM u O AM <br /> `a�\r �-C�5UL1 1► 1Gt�1Gl. ¢�"' _ ` � � S 0 PM a 1 O ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ® Active a Passenger ® Generator 10 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ( I New Tire Dealer AD Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 EXTJ N <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (S In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentstunJ <br /> o r a,re_�'% (9f (XrN Ce_M1, <br /> Inspection Form Included: Q ��� (967 <br /> Oq �r-� ^117 <br /> Comments Included: ® to J <br /> BuQHess Rep's Signature Phone Number Insp or's Signature Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: � w NJ �[E_jX]AjMj P 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />