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0 Waste Tire S&ey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of California I 1 - 1176684 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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: r 3 Z IS Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ste„ nM,� V1W O CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name V - <br /> Inspected By Inspector <br /> Physical Address o <br /> MWM('_Ui Pd . <br /> Inspection Date L © / ( '-4 / + ' <br /> CA '15'3 3 cj <br /> Time In Time Out <br /> Business Rep Titlef' ® AM / S AM <br /> 5- <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude - Q Hauler -Q-Indoor -- <br /> O ® Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) /q/1k /A <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 Q Agriculture Q Shredder ® Other --� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS V� <br /> - - -- - ---- 0 Notice Of Violation 0 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 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 /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years �� o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations10 1 o <br /> O Other:§ <br /> Comments <br /> u <br /> Inspection Form Included: 2 � <br /> L <br /> Comments Included: <br /> Business ews Signature Phone Numbers Inspector's SignatWe Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: tvl EXAM E I 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />