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Waste Tire Su ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1255816 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and'Recovery <br /> Recovery(CalRecycle) <br /> Part A-SurV� BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /L G� Inspection Type(Fill one) <br /> Site Suffix: -T 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L (Jt.y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 01 TO-AD Yb <br /> Physical Address Q I Sfl-u -X 131` <br /> Inspection Date ('> � / .7 <br /> Time In Time Out <br /> fJ <br /> Business Rep Title v I /, �� AM 7 0 AM <br /> Te6�C� C a��c.�n CSu�� PM (� C� � A 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 /> Q Active Q Pa s� enger Q enerator Q Outdoor <br /> kip-mO 0 Closed Q Altered-- <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 16 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder a Other 1t�.v <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 /> (Required for NOV or EXn <br /> Q Q N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> Comments uDaDja_bL._, 'N YL a4bw Lo-yN Ac4u.— oN__`E'-" a t <br /> '-�l,�A-���a rt L�� l l�¢�i 1..� ��(�l..ut7��+1t/L � G�� o�CCII�-✓n <br /> ma lC mAuR�a <br /> {�,�r �l.,af-EL• !MRe <br /> �Inspection Form Included: QComments Included: Q NuBusiSignature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />