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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1242483 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page I <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 _ Q Inspection Type(Fill one) <br /> Site Suffix: l �p 1 I Q Routine 0 Re-inspection Q Referral Q Observation <br /> LocalC /'���L� If Referral,choose referral type(Fill one) <br /> Identifier: Q� �OUl�;� 1 7 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PQebUfs -TircS 3 <br /> Physical Address I - CS CI TTO <br /> a3os s , A� r PUft Lv _ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep (� Title 0 O AM / 0 AM <br /> PM (� 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 /> e Q Active Q Passenger Q/Generator Q Outdoor <br /> o ® Closed Q Alterer/A , ,7 N/)4 <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - O Planned O O`FR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 I v,1A <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> �Notice Of Violation � Extension i <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX N <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement � <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 10 1 Q 1 Other:§ _ <br /> Comments 1�S c,J�p Ula 1/)S G(1- / „�-� 0 l� Z <br /> UkC- 6k A �� vJa a �. <br /> S <br /> awc \r 1, oLe����c1'� `ll c(,s Qc r, C0 r(-L�I"c�/� <br /> Inspection Form Included: O Q <br /> o fel 94(21A)t1Comments Included: &e /ps nuL ��317 <br /> Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: � � IEIXIAIMIPILIEI 1112131 <br /> 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />