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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1230076 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 - <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA_-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1Inspection Type(Fill one) <br /> Site Suffix: 1 -7 g 5 g 3 3 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: <br /> 5-CA-Y" jO��v`� ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � P Inspected By Inspector <br /> Physical Address "� 3 /y _ <br /> X0105 �3 1 N caC INO vc <br /> Inspection Date / IS <br /> Time In Time Out <br /> Business ep Title 1 10 AM C 0 AM <br /> / O PM 1 2 ✓ 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O * Closed Q Altered N��— <br /> GPS Latitude �f/� Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck-V` <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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 /> Comment <br /> � �� o��tia�� �C �c2aS v��c►n.S <br /> I(Ge4m\ '�wcvu-,'\ 6�o,-_ k&Z, <br /> Inspection Form Included: Q �/C,`��"'✓ A�.N� - U <br /> Comments Included: Q i <br /> Business Rep's Signature Phone Number Inspector's Signat-ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V E X A M P L E 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />