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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1176743 <br /> Ccyclin and le 181 <br /> cover (Ca] 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- l u Q ,tom Inspection Type(Fill one) <br /> Site Suffix: 1 ` -1 v - O I 11 Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: 5 om ��Cl �� n l�u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> (,t <br /> Business or Facility Name ` Inspected By Inspector <br /> lU(lU�0 L�v,si <br /> Physical Address IQ <br /> 0I�)'(o �Qf�vf�r�� Dr- <br /> jA 0 c, o — <br /> Inspection Dace I � � l <br /> C,I� `�SZ1Z- <br /> Time In Time Out <br /> Business Rep Title hh AM 9 AM <br /> I V V O PM- O PM <br /> 4�►mob 6'Ik m s. <br /> - ---- — - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 7 I <br /> $ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive I* 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 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 ® 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 /> W <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 <br /> ��- lx u <br /> Inspection Form Included: Q 0� yt �G <br /> Included: — - _ ure <br /> Comments <br /> lu ss ep's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: ( �� E X A M L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Coy: ® ■ <br />