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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1244951 <br /> CalRecycle 181(Rev. (Ca[ 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- inspection <br /> Inspection Type(Fill one) <br /> Site Suffix: Q Routine ® Re-inspection Q Referral Q Observation <br /> Localr--� If Referral,choose referral type(Fill one) <br /> Identifier: �� J O C 1AI-N (01A � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address C- <br /> 1Z3 � � . L��rker WvJ_ <br /> Inspection Date / 16_ / I 1, <br /> A fl r CA q S-LO6 Time In Time Out l� <br /> Business Rep l / Title 1 C O PM Q ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i '50 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR • End-Use 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 n <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other O'u, Elul p f 5vl � <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 <br /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 Qsl UuS 1 'k'A <br /> a21 <br /> '� y1 �lS�U. � x"71 S ��'•r2� �, <br /> c'k % v46 �, ti ��L S'f �v! S An'� d1 TLTC 1- G •A <br /> Inspection Form Included: Q i - . <br /> Comments Included: Q — - <br /> Business Rep's Signature Phone Number Insp tor',Sigyll'nat a Phone Number <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: EXA P E 1121362081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Co LEA © ■ <br />