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Waste Tire Wey & Inspection RepoWnspection Report Number <br /> CalRecycle State of California I 1 -1176617 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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� Inspection Type(Fill one) <br /> Site Suffix: 3 7 S - 0 1 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cw_j_n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J � Inspected By Inspector <br /> or <br /> JGAM 6OY V',- �-'�EN T'O Le-f 1MC / _ / <br /> Physical Address 3 1 0 /n <br /> 1210 S . GL�oKLw <br /> Inspection Date d <br /> LC�'d CA <br /> S Z�U Time In Time Out <br /> Business Rep Title 0 AM ®AM <br /> ,+ <br /> 1 ' 00 Q PM ` ( � 0 Q PM <br /> by, L.a�v I s � ccL - - <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 /> ' ' ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 ® 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 FFA 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 <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 _ <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> LU <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations <br /> Q Q Other:§ — <br /> Comments <br /> .12& rtic <br /> Inspection Form Included: Q <br /> 12 ko5or <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Gorrect:0 Incorrect: � (�� E X A M E 1 1213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop LE <br />