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0 Waste Tire vey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California I 1 - 1176591 <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: C� ( 4 Q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �1�3 t-v 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit Q Other. <br /> Business or Facility Name 11 Inspected By Inspector Physical Address 3 �) - G' O QC1e-� <br /> Inspection Date <br /> CA g� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> I '.' ' I S- ® PM Z 3 `fir 9 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 0 Passenger 0 Generator 0 Outdoor <br /> Closed <br /> GPS Latitude ® Altered 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> -- - - 1 <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q D 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / / <br /> N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> (Required for NOV or EXTJ <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Other:§ <br /> Comments s _/ <br /> na n e >in r 6V-1 7LA f C O&L- C, Cad.& ft-d <br /> Inspection Form Included: 0 <br /> I Comments Included: ® - — - - - �� <br /> Business Rep's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect' X EXAM L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E <br />