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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state of California I 1 - 1210485 <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- O C� � �j � _ /r'•� � Inspection Type(Fill one) <br /> Site Suffix: l ( LJ Routine Q Re-inspection Q Referral Q Observation <br /> Local �� , If Referral,choose referral type(Fill one) <br /> Identifier: G �MAI(+1A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I I <br /> Physical Address O� S S 39 - 9 D l 6�S-C070 <br /> Inspection Date <br /> cA q <�� Time In Time Out <br /> Business Rep Title O AM Q AM <br /> N r lorN Ia <br /> h e �, <br /> S i � �j a1 I CrS ® PM �, 15 10 PM <br /> e <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 /> ' <br /> 'le0 Active Q Passenger ® Generator Q Outdoor <br /> Latitude O O Closed Q Altered NAP <br /> GPS � O Hauler Q Indoor <br /> 0 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 ® 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 /vu rZ Vfou <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 O 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 /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 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 /> - z <br /> Comments 4)�Ak, ��� 1� lkny <br /> O 7V 1I 0A S CM-- <br /> Inspection <br /> MeInspection Form Included: Q �O� <br /> Comments Included: (a <br /> ROIA" Le <br /> mess Reps gnatur Phone Number Insp or's Signature Ac- Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X q EJXJAJ 1112131 <br /> 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />