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Waste Tire Sup vey & Inspection Report inspection Report Number <br /> Cal Recycle State of California I 1 - 1210436 <br /> CalRecycle 181(Rev.y(CalRecycle) <br /> 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- 1 C _ Inspection Type(Fill one) <br /> Site Suffix: I J u O. '0 Routine Q Re-inspection Referral Q Observation <br /> Locala 1 If Referral,choose referral type(Fill one) <br /> Identifier: Cj 01,n J nLc Gt 1&1 rN O CHP Q CalRecycle Q Complaint Q Educational Visit ® Other <br /> Business or Facility Name _ (! Inspected By Inspector <br /> L�)CASE <br /> Physical Address <br /> C A Inspection Date r7 / Q <br /> Time In Time Out <br /> Business Rep Title //ll ® AM AM <br /> 1 V O Q PM l O y 0 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ,p� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator O Outdoor <br /> J <br /> Latitude o 0 Closed ( Ite eed A) A <br /> GPS Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude — 0 Planned Q OTR O 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 Q Hauler Q Agriculture Q Shredder O Other N JA <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Uj <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 1 Q 1 Other:§ <br /> Comments i t �A 3 C41 TA <br /> UtA <br /> I J r� N <br /> 4)4tn e 70V 41.rfl (0'Li�! V <br /> Inspection Form Included: O ' <br /> Comments Included: QZdI <br /> Business Rep's Signature Phone Number inSALtoridignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM El 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® 0 <br />