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Waste Tire Sul, vey & Inspection Report - Inspection Report Number <br /> CalRecycle State of California I 1 - 1196353 <br /> CalRecycle 181(Rev. y(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- t-) ' - © Inspection Type(Fill one) <br /> Site Suffix: o ( LA , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: {� J(�(�q>�) OU Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 <br /> Inspected By Inspector <br /> P Q,`S u,,.t,s 0+ L AA 3 9 <br /> Physical Address ' Q CS CoTT6 <br /> �S3 C . QiInc + <br /> 1 (>14D <br /> (>1l. O Inspection Date <br /> �� `t Time In Time Out t _1 <br /> Business Rep n 1,, Tittle O AM O AM <br /> Ltn� (� 6G�CfC,M�Y` 'jQ(�,rCX.Q, Qr- 49 PM � � � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) `l C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active 0 Passenger '® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 N <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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments n 0A, 11Q_ 1J�� S�L ��i n5�2l��lrbr t <br /> N0 )1)-016c` 1 Un C 0 c on ce j n- <br /> Inspection Form Included: Q ,Q <br /> Comments Included:® - `-f(aos5 f,( <br /> � <br /> Bushes Re s ignature Phone Number Inspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM I L 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Coy: © ■ <br />