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Waste Tire Sur vey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle181California I 1 - 1196367 <br /> CalRecycle 181(Rev.y Ho) 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- 0 Q _ Inspection Type(Fill one) <br /> Site Suffix: 1 Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local ' <br /> If Referral,choose referral type(Fill one) <br /> Identifier: q� J OP�UILI^ tom Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> W e s - , QC' cwQr W c a 3 e E�c c5�SO <br /> Physical Address <br /> SSS S_ E1 00rc, . <br /> �� Inspection Date"' Time In Time Out 1 <br /> Business Rep Title O AM O AM <br /> ' O ® PM 3 0 1b PM <br /> J- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) d� 1 r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed ® Altered <br /> ��� Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - ® End Use Container <br /> Q Planned 9 OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer * Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) 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 /> Lu <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 Other:§ <br /> -- z <br /> L]� 1 <br /> Comments <br /> 13 Ce (A-eA +If , 7N10_1 <br /> ('7J('_C' e_A <br /> Inspection Form Included: ® �� S/3- <br /> Comments Included: ® <br /> Busine Rep's Signature Phone umber Ins a tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: g EXAMPLE 1 2 3 162081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® 0 <br />