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OZ Waste Tire Soe & Inspection Re or. inspection Report Number <br /> CalRecycle y p Rep <br /> State of California I 1 - 1226301 <br /> CalRecycle 181(Rev.y(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- O 1 Inspection Type(Fill one) <br /> Site Suffix: V J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` �� t If Referral,choose referral type(Fill one) <br /> Identifier: JG�1� J o0ji't) (o'Ll,n 0 CHP 0 CalRecycle0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addres l lis(OTT <br /> U n col S. <br /> " y Inspection Date <br /> Time In Time Out <br /> Business Rep Title O O 57 (6 AM O O * AM <br /> l QPM QPM <br /> 1 a lv S 1��cr�� s,�P- c, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ® Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use e Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet • 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 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 /> a <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 o <br /> 010 Other:§ <br /> Comments T e_ 11 1) <br /> I <br /> NO Vi lgi'1m.� C?1 L S C ' (A)Lnurn, <br /> Inspection Form Included: 0 // — <br /> G Z" r <br /> Comments Included: 0 — -- <br /> Business Reppe is's Signature Phone Number InsSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P E-/f 1 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: �� <br />