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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177530 <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: 3 , I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 00 0&1 U Cv u{� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> (..�a�re� sorts •L n�. 1 <br /> Physical Address J o/ C <br /> S Z.o�b <br /> 2)uo s . Fay rmon� A�e� <br /> 1C q 5a�b Inspection Date <br /> b t Time In Time Out <br /> Business Rep Title 0 O AM AM <br /> J ( l <br /> ,Iv (CAJ-4 e l l - 30 [ r 1 Q PM l 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 /> &Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered Ph <br /> GPS Latitude 10Hauler Q Indo r�7 <br /> O Q Inactive Q TrU�nn,,I��7�I <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 J§ Hauler Q Agriculture Q Shredder ® 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 EXTJ 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 /> 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 /> '010 Other:§ �sI l^ <br /> Comments J T i'I11 <br /> G S S CA,3 ZJA o 604')cc 1'n . <br /> Inspection Form Included: Q 00 - <br /> Comments Included: A �o,sSignature <br /> iness Rep's Signature Phone Number Inhone Number <br /> INSTRUCTIONS BACK Correct: Incorrect: E X M JLJEJ 1112N 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pin Cop E <br />