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Waste Tire S't tvey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242453 <br /> CalRecycle 181(Rev.y(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- 1 L4 / Inspection Type(Fill one) <br /> Site Suffix: ` lD 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: Sofas J 0A,I LAI J\ 01JUfn� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A- A - < � SA Air\ _ /, h <br /> I Physical Address 1 / ) Gs t OTT b <br /> )--q ot� j r L n- - <br /> ^r z1S Inspection Date y / l L4 <br /> Time In Time Out <br /> Business Rep Title p i ' S O AM ® 0 AM <br /> �F AV� 1'p 11`i _1![h ( f1q/` J 1� 0 PM S PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' ) ® Active O Passenger Q Generator • Outdoor <br /> GPS Latitude O Closed Q Altered O Hauler • Indoor <br /> O O Inactive Truck <br /> Longitude - Q Planned OTR O 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 O 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 1! Other <br /> 1 � <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O l0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 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 <br /> in Compliance-No Violations o <br /> Q Q1 Other:§ ], <br /> Comments AI tel./W G Jy/C. ) so <br /> uj 41� naed - <br /> l� y i )'0--\ n <br /> Inspection Form In de <br /> 0&-317' �2 <br /> J - o <br /> Comments Included: <br /> siness Rep's Signature Phone Number Ins&rtor,' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � g EJXJAJ 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y LEA ® ■ <br />