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■ Waste Tire Su., /ey & Inspection Rapao rY Inspection Report Number <br /> CalRecycle State of cle181(R 11 e 1242304 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU <br /> _ __ _ _ _ __._ - <br /> E OR BLACK <br /> Business Profile Inspection Details <br /> TPID- Inspection Q I o ' Inspection Type(Fill one) <br /> Site Suffix: 19 (0 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local r ._.' If Referral,choose referral type(Fill one) <br /> Identifier: 501(1�O�tp vl t 3 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> Cc'Xn'ttftu�o `T;fe s d� CYl u�4-f�e� _ (�� C r <br /> Physical Addre l a (Jj r <br /> D:1S k C�D'A( I (�\yCA, <br /> 43k �5101A Inspection Date r] / O <br /> C7(JYL�v� �� "1 Time In Time Out! 1 <br /> Business Rep ''-- Title ®AM ) 1 + , ®AM <br /> �.0.ftf t Z �\Q.I^�r1Gs Cu� frier Wt� t � � � � PM l I "1 � PM <br /> D S �" Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I r-I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( 0 Active 0 Passenger * Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <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 /> O New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> `__ Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 1 Q 1 Other:§ <br /> Comments eo A <br /> _ ), t 1 S v �a ` <br /> vN\1 nl. V� e •... <br /> S <br /> NO \ — <br /> liblk,�I_ un_-, �f CAfcu.s <br /> Inspection Form Included: Q <br /> Comments Included: 0 Li 6 TL <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop LE ® ■ <br />