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Waste Tirt Survey & Inspection Rer. A Inspection Report Number <br /> CalRecycle State of California 1 1 - 1255718 <br /> CalRecycle 181(Rev. (Ca[ Survey For�'�11 - 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- g _ Inspection Type(Fill one) <br /> Site Suffix: I lL7 O 18 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50_0- S(}j` ULjy,) 061kkJA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ?a6h G Com <br /> Physical Address <br /> Inspection Date ' 1 / Q I / l <br /> Time In Time Out <br /> Business Rep Title 1 0 AM 77 r-.-0 AM <br /> I L . U 0 PM L- S 0 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 /> Ul OeActive Q Passenger o Generator I* Outdoor <br /> O Q Closed Q Altered <br /> �� Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 <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 /> 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 UIJ�-L�l� LA_) o+*_;' +i nt�� l �- n✓.1� C- -,te a — Q't TLS I <br /> rz kdl�w'�' ruin nook' <br /> Inspection Form Included: Q Z4&,?_ <br /> 6 2-7,%�A X, <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspectoresignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> � � � EXAMPLE 1123 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA © ■ <br />