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Waste Tire Su. .ey & Inspection Report inspection Report Number <br /> CalRecycle State of cleCalifornia81 I I 1 - 1176523 <br /> CalRecycle 181 Recovery 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 /> Lt Site Suffix: y �j L I ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J-CleAt,L -A:V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam UU Inspected By Inspector <br /> L• N - NJ d ss Rafeec z-s -1' _ <br /> Physical Address <br /> 3 c0 3 a S .� q1 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title M 0 AM <br /> d c�, : ) S ® PM © 3 l , ® PM <br /> AA<A W4,Vt�$C<Lj - -- <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 0 Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler (a Indoor <br /> O Q Inactive ® 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 ® Othera�� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ®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 _�] / M11 <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date ,Z / [.2 <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 EX7) <br /> ® 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 /> 2 <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> A d ` Gd <br /> I Inspection Form Included: O rs 7W <br /> Comments Included: <br /> Busine ep's Signatu P one Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � IEIXIAIMIPILIEI 1112 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® 0 <br />