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Waste Tire Survey & Inspection Repork ,Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1242478 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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- � � /Z � q /: � � � I Inspection Type(Fill one) <br /> Site Suffix: "� 1 b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: s�(� ���l,l l r� ��Ll n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facili Name <br /> l Inspected By Inspector <br /> Physical Address l `� I CS COT <br /> \ v <br /> ) 2L50 S. W-\t&o^ (fit.-'1jS4r_ A- I <br /> Inspection Date / a (0 / <br /> shr_"" CA Islas Time In Time Out <br /> Business Rep y� I _ Title a C) * AM 1 v AM <br /> VlAk /-1 I ll�� FLS �n�.T� �- O PM 0 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 /> • Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR O 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 Tce�n��j�1� 4+)7� f c <br /> kj <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> Q Q Other:§ LL� l ,ff <br /> Comments ,� W uS'l e, r� n Ae1,L 11 U ionJt. O.n 4Y11 S �„fi"� 41 n1k 0 Iy w1'n�l N <br /> �l o's n 6� <br /> Inspection Form Included: Qiiness <br /> /, /Comments Included: ® / /'�p's Ign ur Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � NJ EXAM P E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A ® 0 <br />