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2 Waste Tire Sui ,iey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1196454 <br /> ry <br /> CalRecycle 181(Rev. (Ca(CalRSurvey Form - Page 1 <br /> Dept of Resources Recycling and Recoveecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- I � Inspection Type(Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �jp`� �dr�V� Ca v ��y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> '3T���S 3 <br /> Physical Addresss q - <br /> - <br /> Inspection Date <br /> C;�\ Time In Time Out <br /> Business Rep Title O AM O AM <br /> O 0 PM O * PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passpger <br /> Q Generator Q OruYoor <br /> 0 ! Closed Q AlteN 1ek N Y ` <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 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 ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 1 <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EX7) 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 /> 2 <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 1 Other:§ <br /> Comment + _�```c�►� 'CyV�l.�v��. W C1�S� T��'�I \`����-��bV�+� A'V�_ `\��,5 N <br /> Inspection Form Included: Q <br /> Comments Included: ss epO" Apesine 's Signature Phone Number r's ignature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X} � E X A M P FLIEJ 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ®. <br />