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I <br /> Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> State of California <br /> CalRecycle I 1 - 1177513 <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- I 5 _ Inspection Type(Fill one) <br /> Site Suffix: L J a O , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �` If Referral,choose referral type(Fill one) <br /> Identifier: 'sa-0 J Ca U a'^ ��(�'} Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> AO��S�� S',�s , Inspected By- Inspector <br /> S C <br /> Physical Address ) O I ESCb—rTo <br /> S- 14114 <1 <br /> c �,P <br /> Inspection Date <br /> sail <br /> Time In Time Out <br /> Business Rep Title v O AM O AM <br /> Q-01 <br /> n ® PM ® PM <br /> 2 r 1`�- �Unt s 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 /> ® Active Q Passenger ® Generator Q Out oorr <br /> O Q Closed Q Altered 1n <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 y <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other U�'� -S,e4 <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 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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 <br /> (�0 V 01 A�1t�S LO (a c IA& C j� C n ncOX0- <br /> Inspection Form 179 Included r <br /> Comments Included <br /> usiness Rep's Sign ur Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E1 11 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy. <br />