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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242299 <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- 11 �y 5 �7 © 1 Inspection Type(Fill one) <br /> Site Suffix: "l 1 b 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Locale— / If Referral,choose referral type(Fill one) <br /> Identifier: Istin JBCJIq 111 n l(�1/�f1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L 1 Inspected By Inspector <br /> Physical9dreress 0 ' CS 11 TTb <br /> S cn (Ai rv_In Ave-_ <br /> m f <br /> Inspection Date a, /� U ) I <br /> � °►S?3 v <br /> Time In Time Out <br /> Business Rep TitleO AM n O AM <br /> I U 0 PM •S U 0 PM <br /> �tJ M ��u, �S nQcTwc.-+� m�jC- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � �" <br /> ®Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 9 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 f <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • 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 Date M / 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) 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 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 Q Othe[nr�§ '- <br /> Comments ,L7JV�}1 "an <br /> nt. l/J�/lS iC� 111J� 1 n Tl n� uW ,on 'JS �4kG 1406k <br /> `` �_ZJS �v '- <br /> N 0 �(� �1 A k1 tv�Z ms a.J�.�s „3- Lon tin <br /> Inspection Form Included: QR"A 0-- <br /> Comments Included:0 u� 1� <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: 07v] E X A M L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C <br />