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Waste Tire Su, ✓ Inspection R orMinspection Report Number <br /> ey & ep <br /> State of California <br /> CalRecycle I 1 - 1242178 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> P_a_rt A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection-1 � � � � _ O � Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� CaoCHP oCalRecycle 0 Complaint oEducational Visit 0Other <br /> Business or Facility Name Inspected By Inspector <br /> AT1 _ mak.\ .3 L 9 - ` O 1 1 V <br /> 1 /�}� <br /> PhysicaMddres �VC <br /> Inspection Date C_ 7 / Z 3 / L <br /> Time In V Time Out <br /> Business Rep pp � /Title ? 11D AM n l 0 AM <br /> G � �'t7e �YEA � �� J � � PM 1 C• 1 �PM <br /> `\ 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 /> * Active Q Passenger 40 Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive •Truck <br /> Longitude - Q Planned Q OTR o End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires o Notice Of Violation Q Extension <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 EXnCQ <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q o 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 o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments Vosmy < '1�1b`� ( �Q a T1..iS .0 <br /> o c Macs- rk Gom_'tM <br /> Inspection Form Included: Q ,, /44-/ <br /> Comments Included: o`er 7 LJO <br /> Business R p's Signat Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLEJ 11121j 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />