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Waste Tire Avey & Inspection Reporpinspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245267 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- , Inspection Type(Fill one) <br /> Site Suffix: , Q 7— S ! I I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �i�� v� C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name lJ� Inspected By Inspector <br /> '-Tbry) <br /> Physical Address <br /> Inspection Date � / , 3' 5— <br /> Time <br /> Time In Time Out <br /> Busiinness�Re(p� Title O AM Q AM <br /> 1�! 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 /> 9 6 Active 46 Passenger 0 Generator Q Outdoor <br /> O <br /> 0 Closed Q Altered k '"l <br /> GPSLatitude 0 Inactive Q Truck Hauler Q indoor <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 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 A <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years U) <br /> 0 <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 2cJLCM��,>�. � `�—t^ fl.Q z Y1/Y[< •,t,�-� G1�-`�� <br /> ted- Llr�c�t n u 1 <br /> i O x ,J <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busln ss s Signat Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />