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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1177630 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> F X-Survey BLUE OR BLACK INK PEN <br /> ess Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ( Cl 6 j Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: .c.V1, � v`h G�t�1.fL� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Address AAA MISULA-_ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ®AM *AM <br /> o R-IYL f t ® ® O PM 1 S J O PM <br /> -Spint'01.- 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 Pa sf�1 er ® Generator Q Outdoor <br /> - O ® 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 /> " -siness Type(Fill all that apply) <br /> 'Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> V Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber C ,, <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �� � :4!�'�'�►'l <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 Q Q Notice Of Violation Q Extension <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 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 orFX7) 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 /> 20 <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 I*In Compliance-No Violations o <br /> Q Q Other:§ _ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included:6 ''zA6 -Q67 <br /> S p's "gnature Phbe Nu a 4,1o;rX1SIgj0ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �tVirrect: Incorrect: E X A L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pinkpy: ® 0 <br />