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Waste Tire S#vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1177562 <br /> Ccyclin and R(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- Inspection Type(Fill one) <br /> Site Suffix: l 4-1 41 c5 7 &Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> lVl J �� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address �/ <br /> L9,35- L <br /> OC_K e z� ` <br /> Inspection Date Q 1 <br /> Lob CA q 5-ozje-lo Time In Time Out <br /> Business Rep Title ®AM _ AM <br /> I I ' l am OPM I t �J � OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger 0 Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 / 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 EXE <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Win Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 1 N <br /> &X3 j f 7 /ll G' I!� A?WS uv ,�1-P 4 6 6 f-' (1lCYY1 <br /> � <br /> r j ;ate,l a i3 dc, ly <br /> LX— L S tcf rn 1 t-'i -Gs� /a -? tic G!c <br /> Inspection Form Included: Q <br /> Comments Included: QLf6L <br /> Business Rep's Signature Phone Number Ink or's ig ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E AL E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy LE <br />