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2 Waste Th - Su.vey & Inspection Re, jr, Section Report Number ■ <br /> CalRecycle State of California I 1 - 1176754 <br /> CalRecycle 181(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- Inspection Type(Fill one) <br /> Site Suffix: :3 L © 1 *Routine Q Re-inspection Q Referral Q Observation <br /> LocalG //��,�,,,, If Referral,choose referral type(Fill one) <br /> Identifier: `JCIA �Cr'4tL (\ �--CJva Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 / Inspected By Inspector <br /> cc <br /> Physical Address 99 <br /> Inspection Date � <br /> L—S cc'Joy) 532 0 Time In Time Out t <br /> Business Rep {{�� Title( � 7- 0 AM 9 0 AM <br /> f Y A'h �Jeck'bo VI Z 0 PM ( j O O PM <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 /> 'P Q Active Q Passenger O Generator Q Outdoor <br /> /� <br /> O ® Closed Q Alte ed - ` 4 <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 /> 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 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 <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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 /> z <br /> CommentsAlt" pe4 \ I �� A4J l <br /> Sn 2n eKJCsvr� r` <br /> SM V, JQ 1Vc_� 4!�A- rC •l. �^1P.11� 1 r_ <br /> Inspection Form Included: Q _ <br /> Comments Included: Qot <br /> Business Rep's Signature Phone Number c o Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � ® � E X A M P E K1 1213 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LE © 0 <br />