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Waste Tire Survey & Inspection Report Inspection Report Number <br /> (181 4hyde State of California I 1 -1176585 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> ` Prart A- Survey BLUE OR BLACK INK PEN <br /> -'iness Profile Inspection Details <br /> D- 1 r O - O ( Inspection Type(Fill one) <br /> _.te Suffix: b 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cwt YCI 46-"'VV a"1114-14-3 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �2L-ra171,etitl� <br /> Inspection Date 1 <br /> Loci ; C A 9 sz yD <br /> Time In Time Out <br /> Business Rep Title � � � ® AM 0 AM <br /> '5- 0 PM f 3 a ® 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude -- - - 0 Hauler -0 Indoor-- -- <br /> Q 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) JV A <br /> n New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Jsed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber 9,/ , <br /> (� Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other `��G�cf <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ �_.: W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> 0 1 0 1 Other:§ <br /> Comments N <br /> i= e � {-,���.� ` 'lel`s �tt �—C�yu:•l — t, - - <br /> action Form Included: 0 <br /> Comments Included: -BusX - - - (20y��tGB—� 3 <br /> t —e one Number nape ors ign ure one Number <br /> 62081 <br /> Incorrect:INSTRUCTIONS ON BACCorr ( X A M E 3 <br /> -- -- - - <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LE <br />