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® Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196734 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> *A-Survey _ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> ,,-Ip_ Inspection Type(Fill one) <br /> ©Site Suffix: 1 !Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C- 1�) Co t3� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> j��ress S.�C v� <br /> sical Add _ I C) �AT*V v <br /> C• �S2.7j Inspection Date 1 3o ' 3 <br /> 1f\T J Time In Time Out <br /> Business Rep Titlehh t AM ` C AM <br /> V <br /> 0 <br /> awres 1 0 ' 57 Q PM I O J 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 Passengr Q Gener r)OX �Q Outdoor <br /> 16 Closed Q Aped ' rr <br /> GPS Latitude Q Hauler Q Indodr <br /> O Q Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Jew Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed 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 /> 0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *in Compliance-No Violations o <br /> O 0 Other:§ <br /> CommentsT+�.\,��� <br /> n2�[`�o��Qy i` c�S <br /> AQ `b P6 C& /fi1L n e.� pV <br /> Mitt <br /> o� �C�•�`� �riCc����Y`1`7 1�C�l��`�c <7�c ,�."��`f� �C����.�i� 1. y5C ` ` <br /> rection Form Included: O <br /> Comments Included: Q - - - ����� <br /> Bu ' s Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:10 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />