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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1210483 <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- 1 V7 0 a - Inspection Type(Fill one) <br /> Site Suffix: J V ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S�� "iUGI, U I r% (01A ',' Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name it <br /> Inspected By Inspector <br /> T <br /> Physical Address <br /> S�v� (�er L-o <br /> Inspection Date 5 <br /> Time In Time Out <br /> Business Rep Title C) //,� ® AM I r� (l AM <br /> V. O PM l� l �" v QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (0 Active Q Passenger 48 Generator ® Outdoor <br /> 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 ® 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 Q Other:§ <br /> Comments ��1flXDet�lf� iY�1t- unl tL1�1� <br /> vi X r\VA.S n�,���1 = <br /> NU �l A//6Virt,.%5 ofyja ,3 ()� - <br /> Inspection Form Included: Q <br /> Comments Included: ® (4�U �4�f-04)LACt'6�M <br /> Business Rep's Signature Phone Number Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M V 62081 <br /> E X A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink 4y:L <br />