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® Waste Tire S". vey & Inspection Repor%. Inspection Report Number <br /> CalRecycle State of California T I — 1176410 1 1 7 6 4 1 0 <br /> CalRecycle 181(Rev. (CO) Survey Form - Page 1 1 L <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'Sao J �����(1 Co 1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> L <br /> Physical AddrjUT <br /> Inspection Date 7 Q <br /> (� <br /> CA 1 Time In Time Out <br /> Business Rep Title ® AM O AM <br /> 1 15 O PM v 0 PM <br /> I C. f�o�e- �C� C, e� s.c � s <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> CiPJ, Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) f A!- _ <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 ® Other AN( -`;�l <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 / 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 /> LU <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 /> .Comments �'n ,,��all wu' )P, � r� n -n ( c1f('(" <br /> -- - 'moi Q �� lyl� l�UnS til �� f�uS eA copec-m <br /> Inspection Form Included: 0 � r'zi1�v ' <br /> Comments Included: ^o 111 <br /> Business Rep's Signature Phone Number, Inspec 's nature Pho <br /> Signe Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M L E 1i 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink CopyVol' <br /> © 0 <br />