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02 Waste Tir# ey & Inspection Re"Inspection Report Number <br /> CalRecycle State of California I - 1176720 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form a 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 I 3 Inspection Type(Fill one) <br /> Site Suffix: `1 I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 U n�Q �I n _ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> e(()n -Tn (-. <br /> Physical Address I CD40 <br /> --- <br /> Inspection Date 0 / a 1 i <br /> C 3(o 1 T53 <br /> Time In Time Out <br /> Business Rep Title 0 AMO AM <br /> 1 �J 0 P I Q ® PM <br /> - -- - - --- - —- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger 6 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O • 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 4)41 UAB 0'-� C�mP-.'n <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 /> 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <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 /> Comments � rw— U�)In51y`cl J i 5�� _ � r sly 1 w 44 <br /> CLvld l-46 f)s_ 61 ufe as_Cr�' CutlCef(1, <br /> resy��et�e OJl S e. <br /> Inspection Form Included: Q <br /> Comments Included: Q J o <br /> Business Rep's Signature Phone Number tnspe is Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I& Incorrect: 4;1E X A M L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />