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Waste Tire Su, vey & Inspection Repot` Inspection Report Number <br /> CalRecycle State of California T — ' `i 7 6 7 O /� <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page -1 1 ! (� r} <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I h - Inspection Type(Fill one) <br /> Site Suffix: �/ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local -� I /-_ If Referral,choose referral type(Fill one) <br /> Identifier: S Lt(� Joe' l K) r n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 3 q - I _ <br /> Physical Address l-C � <br /> S����� Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM J Q O AM <br /> PM ' ! PM <br /> A <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 Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler Q Indddr <br /> o/( ff <br /> A <br /> O Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) d1 <br /> Q New Tire Dealer Q Auto Repair ie 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 b6 l�u_�t,A <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 ® 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 /> _ a <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 1 Q 1 Other:§ <br /> Comments �On -t--r u 5 �&fr- Q nCA <br /> �vie. �D�li�3��-�- -_l��S--'(1��•- <br /> rc,,cn S r <br /> Inspection Form Included. <br /> Comments Include 6 �r t_ <br /> Rusin s 's Signature -Phone Number Inspe t is Signature one Number <br /> - - 62081 <br /> INSTRUCTIONS'ON BAC �Correct:e Incorrect: E X A M 1 2 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Cop LE © ■ <br />