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Waste Tire Su, -1y & Inspection Repor, spection Report Number <br /> State of California <br /> CalRecycle I 1 - 1176527 <br /> CalRecycle 181(Rev.y H0) 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- Inspection V Q _ I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C-.4� 76LV V1% 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business <br /> go-rFacility Name V Inspected By Inspector <br /> WCS+SV-�r) Door , - 1 0 1 <br /> Physical Address AM„•,_dCA <br /> Lt Y-,ctC_v CA �s,2 s (o Inspection Date <br /> Time In Time Out <br /> Business Rep Titlley O AM O AM U S ® PM 0 0 PM <br /> --- -- <br /> 3 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 /> 0 Active ® Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive le Truck <br /> Longitude — Q Planned 0 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 i 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 0 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 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 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> —ZCZ�.z1'►�lfL!)L1S�C1���� �1�� "�t` S C�IC:r.� C�(�.�� �, <br /> (CA Al 11IIA15N <br /> . Inspection Formincluded: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correc#: Incorrect: 62os1 <br /> -_- � � g EXA L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />