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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California1R I 1 - 1210369 <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- 1 Q / � � � - Q � Inspection Type(Fill one) <br /> Site Suffix: p _l • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCA,Y1 �O 0.�V�Y1 V N Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 253SS c, SCk,_A� Voc,� <br /> ���� Inspection Date s / "z �{ / l 3 <br /> CA <br /> 9 Time In Time Out 1 <br /> Business Rep Titlet I 6 AM 7 AM <br /> � � O PM � L ' C) � PM <br /> Secv:c_c � <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) t 2 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 I& Active Q Passenger 0 Generator 4D Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) PGOWAX4 <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 ; ct '{ <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 <br /> Q Q 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) <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 1 Q 1 Other:§ _- <br /> Comments t7- Y\ S N <br /> cs_ Y\.o <br /> CYVice m <br /> 01 <br /> Inspection FormIncluded: Q <br /> Comments Included: 0eps c _ <br /> us n ' Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: g IIEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />