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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California T - 1210449 <br /> ■ <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 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- Inspection_ Inspection Type(Fill one) <br /> Site Suffix: 1 eRoutine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local <br /> �- 1 If Referral choose referral <br /> type(Fill one) <br /> Identifier: Sam J O(�u'j 1\ (U1j��V� <br /> JQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Si1v C�' -�'sL.k, r _ <br /> Physical Address 3 V/� <br /> r S�� �� T <br /> 3� v W - v- <br /> CA �5�3� Inspection Date IIVJJ <br /> Time In Time Out <br /> Business Rep \_ Title 0 AM 0 AM <br /> ® PM � PM <br /> ` Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger ®Generator Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GIPS Q Hauler ® 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 ® 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 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datem / m / m <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle q <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or acx7) N <br /> n <br /> v <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 /> 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 NS 1 J ; 1 > N <br /> VCInspection Form Included: Q <br /> Comments Included: 412c79 — 9dz /�� �� ������• <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: IEIXIAIMIPILIEI <br /> 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />