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Waste Tire Sd%ey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1245241 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page l <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- a Inspection Type(Fill one) <br /> Site Suffix: 7 ", I b . Routine Q Re-inspection Q Referral Q Observation <br /> Local //'' If Referral,choose referral type(Fill one) <br /> Identifier: �G V w O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v 1 Inspected By Inspector <br /> c,�r <br /> dress a �,1„ew`: cad <br /> Phys ca)Ad301 - l C) I M Ael e <br /> Skr`I Inspection Date <br /> -�c, .�o Time In Time Out <br /> Business Rep Title AM0 AM <br /> /� ` <br /> � 1 1 • S 0 O PM Z_ { 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 /> 0 Active O Passenger a Generator Q Outdoor <br /> GPS <br /> Latitude O Q Closed Q Altered Al O Hauler Q Indoor <br /> 0 Q Inactive 40 Truck <br /> Longitude — Q Planned 0 OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair .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 Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> F <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> O O Other:§ <br /> Comments VC11 -`cam �_i r e __-� <br /> Inspection Form Included: Q _ <br /> Comments Included: �� <br /> Business Rep's Signature Phone Number Inspecor's Signature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK [Correct* Incorrect: N NJ jjjjjjjjE X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />