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} <br /> Waste Tire rvey & Inspection Repoi Inspection Report Number <br /> Cal Recycle State of California I 1 - 1176713 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I �"f V © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / c> , <br /> / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicOlAddressss 4944 Y 7 9 _ / I `� ej <br /> Inspection Date <br /> S�cic 1z� C 9S !iS- <br /> Time In Time Out <br /> Business Rep Title a AM ®AM <br /> j� <br /> 61 ' S _SQ PM C7 Q 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 <br /> Q Passenger 0 Generator ® Outdoor <br /> -GPS Latitude D Q Closed__ Q Altered antler lad©ar - <br /> 0 Q Inactive 9 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 /> Q Q 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 or EXE 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 /> I � <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 1 Q 1 Other:§ <br /> Comments <br /> 4f 3�- '40e7 C <br /> Inspection Form Included: Q y[ <br /> Comments Included: 4Rep <br /> - Busiature Phone Number nspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct ] Incorrect E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operato Pink Copy:LEA <br /> r <br />