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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226249 <br /> CalRecycle 181(Rev. (CalRSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(Calecycle) <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I t-� - Inspection Type(Fill one) <br /> Site Suffix: 1 l , 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: OLD 0Q1 LA'l n C0U'n� Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physics Address oar �A 3 1 - 1 0 1 C'stvt6i <br /> 1100 S _ Cv ecvo e_e_ l_.n. <br /> Inspection Date <br /> (�o ot� 5�t10 <br /> Time In Time Out <br /> Business Rep Title 1 Q 0 0 AM 1 1 <br /> IA`un me-p 1,' 0.r m PM — PM <br /> C , <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> 1p Active • Passenger je Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q 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 4P Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> QO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / <br /> FU / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Cl) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years In <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ ` L L \\ 1 l L <br /> Comments V_k)L Arm wt,-A4. -C� C c, i�C-C'A llrl Aoj\C. (� \ J 1 yD 5 O�cJj- iA-f\N j <br /> P\ n5 s Gr <br /> Inspection Form Included: Q r <br /> Comments Included: ® -_ �'g3 60 <br /> Business Rep's Signature Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: ( �) EX AMPL E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA ® . <br />