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Oa Waste Tire r--rvey & Inspection Reporp spection Report Number <br /> State of California <br /> CalRecycle 11 - 1255988 <br /> CalRecycle 161(Rev. (Cal 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- + 7 Q ® t - O Inspection'Iype(Fill one) <br /> Site Suffix: 1 J O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1� Oln C(jv-0- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> -D C i.+C,, C � - t I <br /> Physical Address SA-WDO k A rDJ <br /> I.� <br /> 2 c_ Ste tr f-- 5-T Y.e_l L- <br /> fio (-'A- G�5zc�5 Inspection � ' <br /> Date <br /> � <br /> Time In Time Out <br /> Business Rep Title <br /> O AM <br /> I � L � PMI ( Q /O � <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 Pass nger Q Generator Q Outdoor <br /> o r �«-- tom, <br /> GPS Latitude ® Closed Q Altered <br /> 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 /> Q New Tire Dealer Q Auto Repair 0 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 /> 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other C,re�ni✓ V✓�t`, <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 /> 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 /> 2 <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 ,.1, h.c_ d( �1 �4-d- '�C ( <br /> �l�.�i-t/�., � (uvc�.�-✓� . ��'� �i.�-aa�-s <br /> >�rJ l n w' (,� ,,- -b C kY�se_., - <br /> Inspection Form Included-0 <br /> . <br /> Comments Include 7 <br /> Busines ep's Signature Phone Number Inspector's Sin,;, Phone Number <br /> INSTRUCTIONS ON BACK Correct: X IIII 62081 <br /> Incorrect: E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />