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Waste Tire SL. vey & inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle l 1 - 1226573 <br /> CalRecycle 181(Rev. (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page "1 Vv <br /> Part A- Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I 6 o, g a Routine Q Re-inspection Q Referral Q Observation <br /> Local �``�w- If Referral,choose referral type(Fill one) <br /> Identifier: SCI-A �C->��V1� Q CHP Q CalRecycle Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 1 U ( Iq t z t yyI I <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ®AM 0 AM <br /> 0 : 0 C) O PM 4 C7 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 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 Datem / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle -q <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> I <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 w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> - z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signat re Phone Number 14je nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />