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Waste Tire Survey & Inspection Report , Inspection Report Number <br /> CalRecycle State of California I 1 - 1230321 <br /> CalRecycle 181(Rev,y(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- r/ r� '{� T] O ( Inspection Type(Fill one) <br /> Site Suffix: I J / 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Locall If Referral,choose referral type(Fill one) <br /> Identifier: San's a Id 1� �(�1W Yl� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address 3 - 0 e%S&t)'TTiio <br /> on <br /> L <br /> SZu <br /> Inspection Date� <br /> Time In Time Out <br /> Business Rep Title O AM ? O AM <br /> 00'\r6 S f � �1N�1C/' O Q IR PM 3 d PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �, a. (� <br /> ' ® Active ® Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> �aPs Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 c <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �_k r FMA( <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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> _ a <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 /> 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 <br /> �Le�V-1�Jes 14 —tee fel,c b� c Unce n <br /> Inspection Form Included: Q f�L%•�/_ J�� 419 ,,J��,1 ,l^ <br /> Comments Included: ® J v <br /> Business Rep's Sig a ure Phone Number Inspe .1.Signature Phone Num er <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X*q]l EXAM L I E 11 2T3] 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop LEA <br />