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Waste Tire SL. vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242507 <br /> CalRecycle 181(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- O Inspection Type(Fill one) <br /> Site Suffix: D 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I �N If Referral,choose referral type(Fill one) <br /> Identifier: A J 0 U L&I'1 `�� � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> me-Y,71 to Ti fe. J 0 P 3 q l <br /> Physical Address b 1 (,:S(,OT TO <br /> 1 <br /> Tjaj �. UJCbrr 1',r�I V e - <br /> Inspection Date 1 / 7 0 / <br /> S40 A `l5:)_6 <br /> Time In Time <br /> Out <br /> Business Rep TitleO AM O AM <br /> d ® PM � O v � PM <br /> V)r�fti10 SunC�C,� O1�ncl" <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 /> 4@11, Active 0 Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> • 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 /> 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 CR <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 /> f <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 0 In Compliance-No Violations o <br /> Q Q Other:§ 1_ - p <br /> Comments K'qp�' 1n5!0P.(�L\U-� l�lu (yam 41Vl� S �ia�e. ,riA 4-44 Ls inI CA)t1 S <br /> Inspection Form Included: Q <br /> MA <br /> Comments Included: ® <br /> Bus ess Rep's Signa re Phone Number Insp ture or's Signahone Number <br /> INSTRUCTIONS ON BAC ct: Incorrect: E X A E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L A <br />