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Waste Tire SLh ..ey & Inspection Report nspection Report Number <br /> CalRecycle State of California 11 - 1177612 <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: } 5' -l © #Routine Q Re-inspection Q Referral Q Observation <br /> LocalC� � �Q��� ����� If Referral,choose referral type(Fill one) <br /> Identifier: --�FiL Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address _ <br /> t O t A9,9-060L,4 <br /> �-( Inspection Date © Z / 1 <br /> CA `�5- Time In Time Out <br /> Business Rep Title OrAM ®AM <br /> C) Q PM 9 0 Q PM <br /> Y1.1�w�. C�'G�VYI�i.►'l ✓�6t►1. ✓ <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 -0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q db 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 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 <br /> In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> G ' <br /> Inspection Form Included: OZ' <br /> Comments Included: <br /> _ BuAllesE ep's Sign&de Phone Number 1 cto s ignature Phone Number <br /> LX <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � � E X A P E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : ® 0 <br />