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Waste Tire Su. iey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1210342 <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- 2 _ O ' Inspection Type(Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> I <br /> Identifier: CLQ �yaq V n Cys) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> YV'\aV� I d 1 <br /> Physical Address ?j 9 N A T�v <br /> b� Kb Q� <br /> 2 Inspection Date 6 / 07 / 1 <br /> Time In Time Out <br /> Business Rep Title *AM 1A <br /> ® AM <br /> �-� C-r-0— QW <br /> 1Q'2. In�� � C� S � PM � "l S � 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 /> *Active • Passenger • Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive • Truck <br /> Longitude — Q Planned Q OTR O 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 r 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other /�/`U`l t l� ► `r Q �2c U\�e <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 <br /> 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 EX) 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 o <br /> Q Q Other:§ <br /> te, � z <br /> Comments uAc skZ rR_ %y\c Pe Azn Yl QyN e- <br /> - NG V•o�a�b�� aC r��S 0� corcern <br /> Inspection Form Included: ( > . 20,y_ l6j? Z <br /> Comments Included: Z` 3 �! L 3 e_) <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: � � � IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />