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Waste Tire Survey & Inspection Re oif Inspection Report Number <br /> CalRecycle p _ p I 1 - 1177833 <br /> State of California <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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- J O Inspection Type(Fill one) <br /> Site Suffix: 1 J ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local 1 C If Referral,choose referral type(Fill one) <br /> Identifier: (1 O G1,q l/l 1 fl �LI�1 V1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 1 Inspected By Inspector <br /> U� & �fun5Qort 3 <br /> Physical Address V Cs <br /> vlc�b Ganav, Q un ces � c- <br /> Inspection Date t / 3 I / <br /> -Truk(-lJ� �� 953 <br /> J Time In Time Out <br /> Business Rep 1 n 1 Title <br /> O AM O AM <br /> Y , n n W�� �. I S; ® PM b 5 is PM <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 /> Q Active Q Passenger ® Generator Q Outdoor <br /> Latitude O • Closed Q Altered N/4 <br /> CIPS Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR 0 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 0 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle -4 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> Q O Other:§ 11 4 L1_ <br /> Comments <br /> 3'rli\ `A�(A nae= <br /> 011s a J u i Ce s___O.�_Cuncen,. <br /> Inspection Form Included: O <br /> Comments Included: 0--�' U — <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L I E 112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pin Q0y: <br />