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Waste Tire Su. Vey & Inspection Reportslnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242305 <br /> CalRecycle le 181(Rev.y(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- a 3 1 , n I Inspection Type(Fill one) <br /> Site Suffix: l "l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� l If Referral,choose referral type(Fill one) <br /> Identifier: S(�(� �/��, ltil �� 1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I \\\\ <br /> Inspected By Inspector <br /> R. L • Powe LL 3 9 <br /> Physical Address C-su)TTo <br /> 2,3 5314 A rtVki,r <br /> Inspection Date � / � <br /> C s cu,1 Or-, CIA S3Z�0 111 <br /> Time In Time Out <br /> Business Rep L Titlle�jj� �^� 0 AM 0 AM <br /> D <br /> PM � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 16 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / M. <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE A <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0I Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments 1 r <br /> s 1Dn <br /> 0A nCA S 10 6tUa <br /> —11 i�M M61)n5 0 t c.i,r(.-",L r& r dLtuL <br /> Inspection Form Included: 0 / (Ns 637 "W/IV <br /> Comments Included. . l J ( 7S <br /> Business Rep's Signature Phone Number Inspe t is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EJXJ 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C py L <br />