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Waste Tire Su. ✓ey & Inspection Repork inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1230381 <br /> CalRecycle 181(Rev.y(cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � 1 � ` Inspet�i Type(Fill one) <br /> Site Suffix: L Q 1 �RtSutine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: h ��,y�n �� Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> p6s <br /> Phyl AATTQ <br /> sical Address d <br /> F` SZ3 Inspection Date 0 <br /> Time In Time Out <br /> Business Rep�Y Tiitl+e� 0 AM 1 0 AM <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 0 Generator Q Outdoor <br /> GPS Latitude <br /> O 10 Closed Q Altered/,� 0-m8 Indoo <br /> O Q Inactive Q Truck V` <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <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 11 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other TNC�II�R �e ` <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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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:§ <br /> Comments •� � <br /> C, <br /> p�- <br /> t �Rc�ocv„\A� �:ce 5,ec�%cQS- T:re 0� V- �' c�— <br /> '�v.�2 (�.e� �Mt,�c� ��o��t2 S�•c��.,,. '2c� •��°I�S13—o��<CloSe '��'1� (S7_ict`1ISQ1 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> 4Buness ep's Signature Phone Number Inspector's Signature Phone Number_ <br /> �,( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � NJ E X A M P L E 1 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />