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Waste Tire Su. Vey & Inspection Report h-pection Report Number <br /> State of California <br /> CalRecycle 11 - 1177822 <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- i .> a1 1 a, s7 _ O I Inspection Type(Fill one) <br /> Site Suffix: 1 Q Routine Q Re-inspection ® Referral Q Observation <br /> Local _ ` If Referral,choose referral type(Fill one) <br /> Identifier: {-, J Q C1 Ul1-, Q CHP * CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 3 (31-AAA' s C�o�af(_N �0� 3 - o <br /> Physical Addre s 1 1 G S-1 LAO <br /> ) <br /> 215 5 N. LJ iI S u>1 L� l.11lJ����v// <br /> Inspection Date a / V V-7 / 1 -3 <br /> CA 9 cozoS <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> • O PM O 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> PSLatitude O ® Closed Q Altered N�A <br /> G0 Inactive Q TruckN/pQ HaulAyI)a Q Indoor <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 Q Other N/A <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 CalRecycleLn <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 /> 4 W <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 O p Sir 1 F L 1 1 <br /> 0'1 0 (A A-1n; s -UAC n - <br /> Inspection Form Included: Q 'j "Signature <br /> Comments Included: Q gt <br /> Business Rep's Signature Phone Number Insp tor's hone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X*qQEjXjAjMjPjLjEj 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />