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Waste Tire Stey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245305 <br /> CalRecycle 181(Rev. (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: 1 �, B c 2 V f S Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: ��� )OOzc�IL- ^ �vly <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physicdra-\ e��-S / " w�t-, �\S� rY\C <br /> A ���� Inspection Date <br /> CA <br /> Time In Time Out <br /> Business Rep (� Title r 1 0 AM 1 �J 0 AM <br /> V <br /> l 6 0 PM Y ` ' �� ®PM <br /> y 4 � Operational Status The 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 Q Passenger #-Generator (*Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive O Truck <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 /� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other �v�� h . Vl_r2 r <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 / m / 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 EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments if <br /> VKJ <br /> GC �rPoSc)�Inspection Form Included: QComments Included: nature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ONct:0 Incorrect: E X A M P I LJEJ 11 2131 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />