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t Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> CalRecycle State of CaliforniaI 11 - 1226676 <br /> CalRecycle 181 Rev.y 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- Inspection O Inspection Type(Fill one) <br /> Site Suffix: I # Routine Q Re-inspection Q Referral Q Observation <br /> Locali-- If Referral,choose referral type(Fill one) <br /> Identifier: S� J Q LLQ n CC Y,4 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> & � �� ry - I <br /> Physical Address 3 b l Cs <br /> �l ��� G� �Sa,� Inspection Date <br /> b <br /> I(Z, Time In Time Out <br /> Business Rep f Title , 5 S O AM 0 AM <br /> PM ® PM <br /> SOperational 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 /> �j <br /> ' • Active e Passenger 0 Generator Q 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 ® 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 <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 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 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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ --- l^ -- <br /> Comments �l 1� oUl�l N-- W�tc_ A'j a� 1 '� (in 1 S Aa ke,a,0 6k E `u <br /> a ' <br /> StAUvJ ) r\ tA,S <br /> me) U1(�,LAlM0 l bS a (eL'(s eft' C.UJl2e,1n- <br /> Inspection Form Included: O - <br /> Comments Included: ®- - - <br /> BGsi ss Rep's Signature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: W EJX A l Ej 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py- ® ■ <br />