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2 Waste Tire Avey & Inspection Repor ,, Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1230349 <br /> CalRecycle 181(Rev. (Cal 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- .� f'1 q r _ - 0 <br /> Inspection Type(Fill one) <br /> Site Suffix. l LQ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localt unl� If Referral,choose referral type(Fill one) <br /> Identifier: ISQn JOu t41'\ Ch <br /> 1, �J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C.en�f-\.\ (fAkI 'w 7fu.tjt Ct;les Sults 3 _ ( 0 1 <br /> Physical Address Cs LC7TTv <br /> liaQi s - I-I �fl�n Ra� <br /> Inspection Date 06 � 1 S <br /> rf to C'\-\ CcL m`p Time In Time Out <br /> Business Rep Title O AM ` O AM <br /> ukM I 9 PM 1 b 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (7( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �f * Active Q Passenger ® Generator Q Outdoor <br /> C Q Closed Q Altered N/,,q <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 <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 /> 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 EX7 <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 /> ,,��++ j�. ` �� 11 "� <br /> Comments L ill"\ �Il L/VL.Sf Qi�l Ccs nS�athl'��. AJ0'�2 �/l fl�G. PJl��J1 'I' �'(�11 tom; �► <br /> Nc, N (AA+g (nS 01 w1UAS V7 LUn(jern- <br /> Inspection Form Included: Q <br /> Comments Included: ( � � �21�gJ4(ng 3178 <br /> usiness Rep's Si ature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: E X Aj IL5� <br /> 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C © . <br />