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r Ins ection Report Number <br /> Waste Tire S.. .ey & Inspection Repor, p p � <br /> State of California <br /> CalRecycle 11 - 1176436 <br /> CalRecycle 181(Rev, (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 /> Site Suffix: f d • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> V i CAO i-i G, <br /> Physical Address <br /> `J Inspection Date / C) / <br /> � ct- Ct- e <br /> Time In Time Out <br /> Business Rep Title / / J 10 AM O AM <br /> 1h �C'(K/�W G�- �jGLt�;t-L+S� !`ztLS�1 ! / 0 PM 9 i�Z 6 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 2 f <br /> (0 Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • 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 ® 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 EX7) <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 r' r <br /> 101, g�-;`n S n�fi(J�r�- � �l��'( Gf�1 o- ea., 4/_�Lp <br /> i <br /> Inspection Form�nc <br /> ncluded: Q <br /> Comments luded: ®— - -- <br /> Business Is Signature Phone Number Inspector's Sign u_re Phone Number <br /> - — -- -- - — -- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink A y: LIV © ■ <br />