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0 Waste Tire Su, 4ey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1210476 <br /> CalRecycle 181(Rev. (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- Inspection�1 Inspection Type(Fill one) <br /> Site Suffix: 1 3 a ! q et © 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �1 If Referral,choose referral type(Fill one) <br /> Identifier: �j 0 J QU,G[A'111 �tD�'�1�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> p I Inspected By Inspector <br /> Uo`kck \ GtfCeI 5'fyi (,z-Physical Address n2 - L C- C OTT 0 <br /> cc ` Inspection Date 3 <br /> CYTO6%�_6^ 1 `lS3 (�S <br /> Time In Time Out <br /> Business Rep Title O PM 19 AM <br /> M � � 5 5 QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> CaP� Latitude Q Hauler Q Indoor <br /> o 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 ® 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 /> 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 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 1 Other:§ <br /> Comments <br /> s _ u <br /> J r <br /> - - ---- SQL CV.rc��-c�,-Q�� l��rr•<-� <br /> Inspection Form Included: 0I 1 <br /> rr <br /> Comments Included: ® _46 92 A)UIUX�3M <br /> Bus ness Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X0 � E X A L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Poly: <br />