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Waste Tire Survey & Inspec��on Reporloinspection Report Number <br /> CaiRecycle State of California �y 11 - 1242505 <br /> CalRecycle 181(Rev.y(Cal ��urvey Form — Page u <br /> Dept.of Resources Recycling and Recovery(CalRecycle) dA� M �J <br /> Part A-Survey BLUE_O__R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ 11 I Inspection Type(Fill one) <br /> Site Suffix: s a V 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / L� If Referral,choose referral type(Fill one) <br /> Identifier: S(,,() ��a t4,j, `0,4111 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Me', �-i f_\4z Cup C tk C-e r)i_�r <br /> Physical Address 3 o-rT <br /> Inspection Date / 1 <br /> lm ur�"ec G �S 33 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM /� 0 AM <br /> 3 U ID PM 3 D 0 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 /> Uj <br /> Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> ��� Latitude 0 Hauler � Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) _ <br /> 4&New Tire Dealer 40 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments fL I f r ': a116k N <br /> �ll 1 U A�7o-i <br /> S 0 U_J tAS Gs�Ce/Y7� <br /> Inspection Form Included: 0 <br /> Comments Included: ® � �'- �v'� �� <br /> Busine Rep's Signature one Number .Inspe is signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: g E I X I A IMI PA I E 1 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop0V_____1' <br />