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Waste Tire Su, vey & Inspection Repor.. Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1242370 <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 /> Site - - 1 ^ O InspectionutType(Fillone)p Q Q <br /> Site Suffix: "� Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50.w. �����, ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> lin 1."T cwnSoco� '91A - N O <br /> Physical Address <br /> C��� Inspection Date Q � / 2- 0 <br /> J / 1 y <br /> �c C <br /> Time In Time Out <br /> Business Rep \ _ Title <br /> � ' � � 9 AM � � '* AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator a Outdoor ? <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler S Indoor ZZ <br /> O Q Inactive 46 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 S 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 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 A In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments \ <br /> S <br /> Inspection Form Included: Q J// 151,174 j to A44 4 <br /> Comments Included: Y <br /> siness Reps Signature P one Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JEJXJA�M� PJLJEJ 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />