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Waste Tire Survey & Inspection Repos Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226506 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- h Inspection Type(Fill one) <br /> v <br /> Site Suffix: lJ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I / ], If Referral,choose referral type(Fill one) <br /> Identifier: J GLS{u n l Uti1�1 I L� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name b 1 Inspected By Inspector <br /> des A vAVt) 3 _ <br /> Physical Address <br /> ) 1 � ��� � Inspection Date l ` / O <br /> Time In Time Out <br /> Business R,e f' �� L ��.1 Title p ® AM i O AM <br /> (,1, (J� C v V �2I l /� I Q PM <br /> ,�•k,� J�Pef1�1SOr V QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (p ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> ® Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ 1 I <br /> Comments 1 ' f��'[ �, Ti Ic l 5 Id`1 I -I UI I(J�.a oi, <br /> Na yi0 L 1_V1s crus C,4 con-orn <br /> Inspection Form Included: 0 2(7,?— 7 2 7- 060' MJ <br /> Commentslncluded: ® _ . O q_ �07 X30310Busine ep's Signature Phone Number Insp or's Signature hber <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V 24) <br /> (� EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : © ■ <br />