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Waste Tire Survey & Inspection Report ' Inspection Report Number <br /> CalRecycle State of California I 1 <br /> 1242350CalRecycle 181(Rev. (CalRecycle) Survey <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page I <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 Inspection Type(Fill one) <br /> Site Suffix: l O �( S Routine Q Re-inspection Q Referral Q Observation <br /> Local t ,1. If Referral,choose referral type(Fill one) <br /> Identifier: SQt) JOtJt�cj LI 1✓1 ��+1`� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ll Inspected By Inspector <br /> N Qw u17�, L7 ()AA 3 J'� <br /> Physical AddressV <br /> 1 1 1 ! CS <br /> lXJ V w �vl lti r(�✓1 S�_ - - - V - - <br /> Inspection Date `7 / -3 <br /> Time In Time Out 1 <br /> Business Rep Trifle l AM 0 AM <br /> f �u ` O 0 PM D O PM <br /> ­ <br /> Operational� t���-� f <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /wif (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1,J 0 Active Q Passenger ® Generator Q Outdoor <br /> o Q Closed Q Altered N 1A <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned i OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) CJ <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 0 Other I XL�'Pq <br /> _ J <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953,-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <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 /> 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 (f13 �(.�fi��s ��L Gl� {�� 40 �^ <br /> �A SAS n _ ��L <br /> - -�Vv 11iU[���-�•,s OJ U kms <br /> U� ��f1Ce n5- <br /> Inspection Form Included: O <br /> 31'7 9 <br /> Comments Included: 042 <br /> siness Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X I A IMI L 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co ® ■ <br />