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r: <br /> Waste Tire SOey & Inspection Repor0lnspection Report Number <br /> CalRecycle State of California 11 - 1255779 <br /> CalRecycle 181(Rev. (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 i Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ) If Referral,choose referral type(Fill one) <br /> Identifier: �� 3L oo CoLF—P, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - J S 1111,Y�V L* P <br /> ," <br /> _ Inspection Date , / Z 3 C fit- �s��j I <br /> Time In Time Out <br /> Business Rep Title % I O AM � O AM <br /> • PM Z c 0 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 QPas enger Q Generator Q Outdoor <br /> 0 • Closed Q Abed �1 n 16,.G <br /> PS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> 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 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> ► o.nr t'r.- CQGvL.ft cin ' z_�, cla:r a-A-4) 4� - yi( LLI nciL� t` <br /> Lb y'cCuLam Cmc o� y c cIx.t�,�x.c� kX45 r_BuXiMs S ACLS rnav 1 d <br /> thus , yoc o >_C4&rt tC"' cif 15-/15-, Q.�.c�rn rnr�►1.� � -�I t io SIJ C_1oi.<Q. <br /> 811-7139 " e L It(2 <br /> Inspection Form Included: Q <br /> Comments Included: Q C7Qq ¢u - Z�' <br /> B ss Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BA K [Correct: Incorrect: X rJ E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />