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Waste Tire S✓ey & Inspection Repor Inspection Report Number <br /> Cal Recycle State of California 11 - 1226540 <br /> CalRecycle 1811Rev.y(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- Inspection Type(Fill one) <br /> Site Suffix: f 3 D 7 0 Z v ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCv�'1 ^CD4 -u >Z�gn�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J J Inspected By Inspector <br /> Physical Address / <br /> D.—ic�AoCA Sr <br /> Inspection Date / I / Q 71- <br /> Time In Time Out <br /> Business Rep Title ! O d ® AMI S S ® AM <br /> QPM QPM <br /> - - U- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 )C1.��� <br /> _ <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 /> 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ A <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 /> -- z <br /> Comments , <br /> Inspection Form Included: Q <br /> Comments Included: @___ <br /> - Busine Signature Phone Number Inspector's Signature Phone Number <br /> - - <br /> ----- - - — <br /> INSTRUCTIONS ON correct:* Incorrect. E X A M E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co : <br />