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Waste Tire Avey & Inspection Repor, Inspection Report Number <br /> State of California <br /> 11 - 1230122 <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- ` Q O Inspection Type(Fill one) <br /> Site Suffix: 1 l l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /- un1 If Referral,choose referral type(Fill one) <br /> Identifier: n� w�U,,o �n `o 1� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> C m �\ 3 9 <br /> Physical Address <br /> C �5o Inspection Date <br /> Time In Time Out <br /> Business Rep r\_ Title ,1 6 AM 2 ® AM <br /> SSC.\Q l�Ylfl�Pi� QSNs1� �. 1 v V�l O PM I I J S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> ®Active 0 Passenger • Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other V�Xwm r'ea;SjS'a�S <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 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 * 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 OtherZ34% <br /> §._ �) _ l k 1,� _ <br /> Comments \�.�71�V�%(V— �UAQ'i i I'c3 A��on (JlII}� o_,AT ,;s Cf�,) _ G(),-A 4"`� <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Bu s e Signature Phone Number Ins tor's Signat a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: _ 4 NJ E X A M E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop �L A <br />