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Waste Tire Sui vey & Inspection Report inspection Report Number <br /> CalRecycle State of California 11 - 1230178 <br /> CalRecycle 181(Rev.y(Cal. Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A=Surve rte._______ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 4 L <br /> ^ _ Inspection Type(Fill one) <br /> Site Suffix: * Routine Q Re-inspection Q Referral Q Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier: �4^�, v`V-\ Co-'s / Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M ^}}1 `�v <br /> Physical Address <br /> Inspection Date 1 / / 1 <br /> S\vC`c.Vo r 03?q52�S `JJ <br /> Time In Time Out <br /> Business Rep �\ l Title \ 2 O AM O AM <br /> `T \�. CVS�j�1C. (�� ✓ O , PM �PM <br /> -—` — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(1Nhole/PTE) 5 O Q <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Is Truck <br /> Longitude — Q Planned Q OTR Q End-Use 6 Container9 <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 EX1) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ \ p \ <br /> Comments <br /> V.i 0. Y' 1, <br /> Inspection Form Included: Q .Q /�_�D —� �`" '4 J'Z <br /> 1 <br /> Comments Included: 7 <br /> BWines Re Sign ture Phone Number Inspec is ignature Phone Number <br /> INSTRUCTIONS ON BACK r Correct:0 Incorrect: � W 62081 <br /> EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />