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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1226336 <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 1lnspection Details <br /> TPID- Inspection 0 _ 1 Inspection Type(Fill one) <br /> G <br /> Site Suffix: l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(�(� J tw(3 owl n cvuk\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> D_s S_ COn u.�� _ <br /> Physical Address O , E5 <br /> 140 <br /> X55 W . CACII\� 5V. <br /> (A �5 20 6 Inspection Date � / V sr� <br /> Time In Time Out <br /> Business Rep Title /, • AM ` �l ® AM <br /> S <br /> �n1 1 1 1 I v � O QPM I I � '`/ QPM <br /> \1 b �bf"ro w) <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger ® Generator 49 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR O 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 C&"4 5'ji" <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS \J <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX, N <br /> r <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 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 O Other:§ <br /> Comments <br /> V1 k�r�u�o W c&1(J'5 cif wnc'�n. <br /> Inspection Form Included: Q� _ <br /> Comments Included: ® —�� - �Inp Busin Rep s Signatur Phone Number gnature Phone Number <br /> V [ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � JJJE )( A M P L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE © ■ <br />