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® Waste Tire Vey & Inspection Repoi Inspection Report Number <br /> Cal Recycle State of California I 1 - 1176624 <br /> CalRecycle 181(Rev. (Ca[ 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- yInspection Type(Fill one) <br /> Site Suffix: I � ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�L Yl .- Com „ i-c Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> G �uti � _L�ti CMYt S'TP�Physicalhj�'T <br /> 02 I'4 c f� I^ c3,,4,, <br /> l�►v�L;b•'r'�alGi <br /> Inspection Date <br /> C_A qS-ZLIO <br /> l <br /> Time In Time Out <br /> Business Rep Title �y Q AMQ AM <br /> v I ® PM o O ® PM <br /> - <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 Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O O Closed Q Altered - <br /> Q Hauler —O-Indoor- - <br /> O ® Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) IyI A ^J/ft NIA <br /> Q New Tire Deafer 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 O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> W14r1'16W '-eIQ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - — - - -- -- O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations - <br /> Other:§ �-----_— <br /> Comments <br /> Inspection Form Included: Q <br /> VC,$ -o.z3 <br /> Comments Included: 0__ <br /> -- <br /> Busine s R p's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BA Correct:* Incorrect: ]YN 70 E Xtk <br /> L 1 Z 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator P <br />