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Waste Tire Survey& Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177524 <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- I Q Q D Inspection Type(Fill one) <br /> Site Suffix: 7j 1 O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: (A J �� ut� u� A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Q '_1 Inspected By Inspector <br /> 1 C. (,\_)cr� ` I�� e_�6t P_S — \JertictIjS �' q� <br /> Physical Address 3 - 0 1 S (46 <br /> 3�9m 5- &,A Ori- U <br /> -VCN CA 9 s3o1 Inspection Date I,{ / / ) 3 <br /> Time In _ 1 Time Outl <br /> Business Rep Title V O AM V O AM <br /> -V 0 PM ® PM <br /> � 1 ( [ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o ® Inactive ® Truck <br /> Longitude - Q Planned 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 ® Other Allikeltik, <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 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 4 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 = <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments n u � 5�,� �� T i61-1 <br /> -con ccTa, <br /> Inspection Form Included: Q <br /> Comments Included: ® - r�Z <br /> Bu i e s ep's Signature Phone Number &Inspecf)�. 'sTignature Aone Number <br /> _4�7 INSTRUCTIONS ON K Correct:0 Incorrect: EXAM L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy.(L4' <br />