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Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California1R I 1 - 1177692 <br /> CalRecycle 181(Rev. y(Cal Survey Form v 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- t - Inspection Type(Fill one) <br /> Site Suffix: / [`� B a 1 j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 111 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S p,- <br /> Physical Address <br /> YG— <br /> Inspection Date <br /> CA Cv�R&4' Time In Time Out L <br /> Business Rep Title 0 AM 0 AM <br /> ® Z_ ®PM 3 C� ® PM <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 /> 40 Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 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 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> i� <br /> Inspection Form Included: :4 <br /> Comments Included: (0 !� y V <br /> u ep's Signature Phone Number I s ec r' ign ur Phone Num er <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM E 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />