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Waste Tire SL.. ✓ey & Inspection ReporAnspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1230138 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-_Survey _ _. _ _ BLUE OR BLACK INK PEN <br /> rBusiness Profile Inspection Details <br /> TPID- j ( �–/ I _ Inspection Type(Fill one) <br /> Site Suffix: 1 l _( (vM Routine Q Re-inspection Q Referral Q Observation <br /> Local �1 If Referral,choose referral type(Fill one) <br /> 1 <br /> Identifier: 5�n J o�.G Lt.1 n Uwr)t� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ` d n 0O <br /> Physical Address ! CS WTr <br /> Inspection Date ('o <br /> Time In Time Out <br /> Business Rep Title O AM 0 O AM <br /> • PM � V � 0 PM <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 /> i <br /> Active Q Passenger * Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ' Truck <br /> Longitude – Q End-Use Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair e 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 <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q Q 14 CCR§18459.1 Tire Program ID Number from CalRecycle W <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 /> Q Q Other.§ <br /> Comments ' 1 1 i t 1 <br /> �n s�u��'1�— <br /> CAL co-rn- <br /> Inspection Form Included: Q -� <br /> Comments Included: �1..iss ep's Signature Phone Number Insure Phone Number <br /> INSTRUCTIONS ON BACK �Correct:e Incorrect: E X A P E 1112131 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink C t <br /> LE / © 0 <br />