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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242452 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part_A_- Surve_Y _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` ^ _ © Inspection Type(Fill one) <br /> Site Suffix: b CE5 o Routine Q Re-inspection Q Referral Q Observation <br /> Local Q If Referral,choose referral type(Fill one) <br /> Identifier: J tkn J Uul LA.", C(�1�11 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � u Inspected By- Inspector <br /> VO4 I��u�� (,6 <br /> Physical Address <br /> 350 ��U��vn �v�- . <br /> G C Inspection Date 3 <br /> (A ` J-zhv� Time In Time Out <br /> Business Rep Title , <br /> I U1 4 1�1�-k�� � O 0 AM C� U /' O AM <br /> �it1�1�\u.�� Ow nsWi�'e• � O PM oma- ' I V 0 PM <br /> Ow Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /_ff' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q G_yegerator Q Outdoor <br /> terbd� <br /> O J <br /> GPS Latitude 0 Closed Q AQ Hauler Q In o <br /> O Q Inactive Q 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 Qg,517C(Q(I <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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments1t_�t.) A , tJ I �5 e KI)_1 <br /> A, 1' ) a S �o�Ler <br /> Inspection Form Included: Q `� ' <br /> �1 Gv � <br /> Comments Included: 0 3 <br /> Business ep's Signature Phone Number &Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />