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Waste Tire S#ey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California 11 - 1255995 <br /> CalRecycle 181(Rev.y(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 Type(Fill one) <br /> Cl <br /> C <br /> Site Suffix: ` ? 3 ` d J 0 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5c, 1,C)OLq V� Co !�f Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 Inspected By Inspector <br /> M L`C T_a.Y\s e o� a ,ova 3 C\ <br /> Physical Address <br /> Inspection Date O O ? 1 b <br /> V;c,0f, C 9 s25 <br /> Time In Time Out <br /> Business Rep Title OAM <br /> , , D S O PM © ®PM <br /> A 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 /> 0 Active Q Passenger 0 Generator 0 Outdoor Zy <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler J1 Indoor 7 y <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned O OTR O 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 O 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ \ <br /> Comments `�y-��V�e �— r�h �S &J <br /> Inspection Form Included: Q <br /> Comments Included: 0' <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />