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Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242525 <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- ' 1 a _ 0 ' Inspection Type(Fill one) <br /> Site Suffix: 1 * Routine Q Re-inspection Q Referral Q Observation <br /> Localr'_ L If Referral,choose referral type(Fill one) <br /> Identifier: Sof) -C7u-N L ►.r) (01 n ]1/� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 1 <br /> Inspected By Inspector <br /> Physical Address <br /> �OO^ a Inspection Date S -- / 0 <br /> t Time In Time Out <br /> Business Rep Title � O AM n 0 ,M <br /> Cc (pot , J IsO 9PM � ®PM <br /> 1 ilJ fx� 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 /> V 0 Active ® Passenger O Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 <br /> N <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 ( � � j I <br /> N b �J i O\Ak�tn3 6j C Q rn_ <br /> Inspection Form Included: Q <br /> Comments Included: it�� / &.Awe. lee 0h7 126 jon)q(p X_70 <br /> Business Rep's Sign re Phone Number Insp tor's Signature hone Number <br /> INSTRUCTIONS ON BACK I Corre t: Incorrect: E X A P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />