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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1230379 <br /> CalRecycle 181(Rev. (Ca[. 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- I5 Q 2 9 - Inspection Type(Fill one) <br /> Site Suffix: 1 f Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5Q, To�q ,^ Gzsv Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> I'c,,w\ Mico ��ns�c�C roti 'S 9 - O 1 <br /> Physical Address MAT-�� <br /> Inspection Date 6 <br /> SkoCk �,n C al$ZIS ` 1 <br /> Time In Time Out <br /> Business Rep Title ��\\ O AM N O AM <br /> 1` Z 2_ v � PM � 1 � �'PM <br /> G<C f C N1� k)-(CP— ���St Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger #Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q 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 (& 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 O 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 N <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`_ S <br /> Inspection Form Included: Q 21C0—'L&-3Z1;`1 <br /> Comments Included: S <br /> u mess Rep's ignatur Phone Number Inspec is Signature Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � NJ EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />