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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1230096 <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- C _ o Inspection Type(Fill one) <br /> Site Suffix: Q J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( JpCA41Lt;, c"A" 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P-0 r\ van (��0ni r-,30-(-N _ <br /> Physical Address 3 I r� 1 cs�,E7TSb <br /> vJ- <br /> �� A 1 53�iu Inspection Date 0 <br /> Time In Time Out J <br /> Business Rep Title c� (� 0 AM 0 AM <br /> ( V <br /> ,v^ UCS (r onin f1 (�Ll ® PM ® 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 /> Je 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 AlterN/ N N J <br /> GPS Latitude q 0 Haulet/A 0 Indoor / <br /> O 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 § Other Res,,jenev_ <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 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 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> 0 1 0 1 Other:§ y j, 1 k G l <br /> Comments Sr11�1�lnl11� (AUS <br /> n4OA = �i� GC�1`uns I1cnleu� Cr (-,)J)(,, co 1 r'_ 11110IN <br /> �b f' <br /> ASS {-i ft-S- cxosc. T4i.D- <br /> Inspection Form Included: 0 1 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Ins tor's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V\ W E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />