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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 18,1(Rev.10/10) Survey Form - Page 1 I1 1242325 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 1 e�I r^ - Inspection Type(Fill one) <br /> O <br /> Site Suffix: ! lJ * Routine Q Re-inspection Q Referral Q Observation <br /> Local , / If Referral,choose referral type(Fill one) <br /> Identifier: 5aA�afl Vll/� �C ") Q CHP Q CalRecycle O Complaint Q Educational Visit O Other <br /> Business or Facility Name _ Inspected By Inspector <br /> ()0_1 <br /> Physical Address <br /> _W6 5 - El fl c )J v st, <br /> Sid c - U nspection Date 7 <br /> A I SLOG II <br /> Time In Time Out <br /> Business Rep TitleAM O AM <br /> � , a , a S 0"* PM O ® PM <br /> �J a1 me-V; AA 40 CrNAI <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger 0 Generator 1111 Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned O OTR 0 End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O 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 Q 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 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 EXE N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 O 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 m <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:§ l <br /> Comments 941,N0, W ask i s OQtiTi'U� �nR. (�/���'li C (�GL�L LI-otA9— <br /> a <br /> -F k10 '(�aw m. n ofed; <br /> Inspection Form Included: Q n�^_ � <br /> Comments Included: —.� "IG l <br /> mess Rep's Signature Phone Number InIrs Sign ure hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: E X A L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink op EA <br />