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Waste TireySUrvey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210493 <br /> CalRecycle i8l(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- _ O Inspection Type(Fill one) <br /> Site Suffix: l "l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �A If Referral,choose referral type(Fill one) <br /> Identifier: SGn G"I Lf IrN (O-IlA ) �1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ,Jl <br /> Inspected By Inspector <br /> Physical Address ' o l G co-CT-(D <br /> 2 (A %3 b� Inspection Date 5 / / t 3 <br /> ,�o n <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 VPM O 0 P <br /> - <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 /> • Active ® Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS 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 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 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 / Ffl / <br /> 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 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 0 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 /> Comments t <br /> uj\ LAO-) '0A4h'& Lkt' (Ain6t %ea <br /> -�Ao_w�n <br /> 3 <br /> Inspection Form Included: Q' < C l <br /> Comments Included: 40— - <br /> Business Re 's gna re hone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: R: q E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® 0 <br />