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Waste Tire Su*,y & Inspection Report spection Report Number <br /> State of California <br /> CalRecycle 11 - 1176647 <br /> CalRecycle 181(Rev. (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- q Inspection Type(Fill one) <br /> Site Suffix: + y l I $ 77- 7 ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^�be�.q;,,_,,y_ ' " _ �J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /1 UU Inspected By Inspector <br /> Physical Address � , �� © � ��,� <br /> r►� lQ�a . <br /> 7 Inspection Date <br /> rct� co 1S 3�'T Time In Time Out <br /> Business Rep Titlec' ® AM r� O AM <br /> 7 S Q PM f o� 1 C� 0 PM <br /> l — - 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 /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Nl A tVI N ^Q A <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 �jr�y <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - -- on <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Titres Q Notice Of Violation Q Extension <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 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 <br /> Q Q Other:§ <br /> Comments <br /> -��ufin� ,nc�z�-- �7a�`s—�'c1E�. �-�•,F,� ,�Cl�uyut <br /> JA.6:�i r <br /> Inspection Form Included: Q ' ` Y68^C)6 3 <br /> Comments Included: ® r _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -_ - 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (� E X A M L 1 �3J <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop 'L <br />