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Waste Tire Su. ,iey & Inspection Report Inspection Report Number <br /> CalRecycle State of California( 11 - 1226308 <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- 1 ^� 3 - O I Inspection Type(Fill one) <br /> Site Suffix: V ' Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: {1 Q{,uI 1/1 1 ^ Coun Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C�C' C VA () C.os o�.A,o� 3 - � � I c) <br /> Physical Address 1 CStT�6 <br /> q31, Qe t-�vJ rnun�,� QS' <br /> S�b� Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> 11 M� f O AM 5 0 AM <br /> oa' 1'r)NC_ V '1 i l�nf l t a QPM � ' `-' ® PM <br /> �"' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Onuttdoor <br /> es Latitude <br /> O Q Closed Q Altered /v /A <br /> CiQ Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR Q 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 Other 4"'1 CIO ces5d�5 <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 / FTI Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 4 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments1 1 � r <br /> �1ti'['� LW v 1Nei <br /> Aj�eA)HkN& (D5 WZ1f1%s 0f Q, ncQfn = <br /> Inspection Form Included: Q <br /> Comments Included: 35--207 v <br /> lAbk--M r7 <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> X q <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />