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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1196399 <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- � � � © � Inspection Type(Fill one) <br /> Site Suffix: Q Routine • Re-inspection Q Referral Q Observation <br /> Local t— If Referral,choose referral type(Fill one) <br /> Identifier: f1 J ttiCt�IAf % C �, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \J Inspected By Inspector <br /> Physical Address `� V ' S COTT( <br /> ` �c Inspection Date <br /> o t,tz.,�o� C� J <br /> Time In Time Out <br /> Business Rep Title (6 AM 1 O AM <br /> I I : ' O PM 1 Z. � O � 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 /> ` � � :� $ `U <br /> • Active ® Passenger ® 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 Q 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 /> 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 EXTJ <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 :f <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 1 Q 1 Other:§ i n <br /> Comments VS Vo%XS �nS �D-, (�JDr3L cin Il1p l3 . 1�-1�5 Ll,—, 1 ®a o" i S <br /> R�` PSI�J+�us ViDla,"1ivnS +nvL gun c,LJfey�en�- <br /> P�o� <br /> Inspection Form Included: O Ip Z�4f�O <br /> Comments Included: Q ""^^^' ( e4`1"�(A75 Z <br /> Bu iness Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: E X A 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C LEA © 0 <br />