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y p Rept—, <br /> TireWlve & Inspection � Inspection Report Number <br /> cle ■ <br /> CalRec p <br /> Y state of callfornia I 1 - 117 7 � <br /> CalRecycle 181(Rev. Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK P E N <br /> Part A-Survey -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l 3 O I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� I if Referral,choose referral type(Fill one) <br /> Identifier: Sa J0a/ U1,r) \ Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> InktoAj_n� t Cu'c_ )n 3 � � �,, C� <br /> Physical Address Y_�l�n J Osco <br /> Inspection Date <br /> S�o "'`'�on CA q5Q Time In Time Out <br /> Business Rep Title Q Q AM I 0 AM <br /> ? (` Sue. QPM v 0 P <br /> mx `(' 1 e'1J� - JY! Ju Operational Status Tire Type Business Role Storage Type <br /> •i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active ® Passenger � Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Container <br /> Business Type(Fill all that apply) -- <br /> Q New Tire Dealer p Auto Repair ® 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 0 Other 04-4L'Lse' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX <br /> Q Q E <br /> N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O 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 /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§((�� , <br /> Comments 1�l�Ll� (AD <br /> ( <br /> Inspection Form Included: <br /> 'L r <br /> p Comments Included: % - 't v <br /> Business Rep's Signature Phone Number Inspec 's Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E X A 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y:L ® ■ <br />