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Waste Tire Su. ✓ey & Inspection Report Inspection Report Nurnber <br /> State of California <br /> CalRecycle 11 - 1177763 <br /> CalRecycle 181(Rev. (Ca[ 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- ' _7 2_ O ' Inspection Type(Fill one) <br /> Site Suffix: G ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fil(one) <br /> Identifier: 5Q101 J b a-T V%'r\ (01U3 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T i 11 rvcV'%,V:� � � - � Q 1 ���v <br /> Physical Address <br /> 11 3a 6 {v' H W r 99 /M <br /> Inspection Date 5 Q 7 / 3 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> r \ � I ' S 0 * PM 2 ` Q PM <br /> TGt'(N',A QWvte <br /> -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 40 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive A 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 <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 /> 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 Exr7 <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 /> 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 <br /> In Compliance- No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> V'Ca0 Ahe aeLvAst. —M rt- N V't s p_Ck'10 r) 6myxe Qvt +6iS <br /> Inspection Form Included: Q <br /> 1 , x` -� <br /> Comments Included: 60 2og 328 <br /> Busi ss p's Signature Phorie Number Inspe or's Signature Phone Number <br /> _ <br /> INSTRUCTIONS ON ACK Correct: Incorrect: W 62081 <br /> g EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />