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M Waste Tire SL_ ✓ey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242435 <br /> CalRecycle 181(Rev. (Cal 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 _ ` Inspection Type(Fill one) <br /> Site Suffix: ` 6 2 —1 c) '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.1f� `5`0� y�h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 cl – ` !M\A <br /> 1002 M• �coaB.Wa� o v e <br /> S kvc_V\C�-v-\ C\ CtS20C Inspection Date Q ! O Z <br /> 7 Time In Time Out <br /> Business Rep 11 Title 0 AM 0 AM <br /> Cvoac V`\2 t&-p,_ _" S &PM �j . ' O 0 PM <br /> � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger IF Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler I* Indoor <br /> 0 Q Inactive * 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 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 I* Other i WC1G 'DC,J slzv(so) <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 EXE 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 Q Other:§ <br /> Comments <br /> GLS 1n p <br /> \01- <br /> esv <br /> Inspection Form Included: <br /> Comments Included: OIL /� ]LY1S JL`f�Za __/�'!l 2,-i-(4&9-,3z84 <br /> 15usiness Rep's Sig atu hone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: E X A M P L E 1 2 N 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />