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Waste Tire SL. vey & Inspection Repork Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242207 <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- � � � © � Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local r..� If Referral,choose referral type(Fill one) <br /> Identifier: L� J GC1 V%r 60V T Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name b Inspected By Inspector <br /> D"362,, - O 1 <br /> Physical Address MAI- <br /> T Q <br /> `ZAC20 arc 11oC5 I - ` <br /> Inspection Date O Z / -2- <br /> / S <br /> 'C'CJG� V1 L Time In Time Out <br /> Business Rep Title O AM <br /> O AM <br /> 46 ( 6 5 wPM 0 PM <br /> � <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 Q Generator Q Outdo/or <br /> O • Closed Q Alter Aipl _ Al(A <br /> GPS Latitude /� Q Haulier 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 /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 40 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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 0 <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 /> 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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments���� <br /> �e_ �rr� � S-`-?S���ara Cjc�L �n e, pv► 1-l�i�5 It rya"� o►.ti1� <br /> JJb�,e-S'•l� 't"�.S �,s��n�sS i S t�c� IG-0C' <br /> e,S v�a� es S T �� SQ <br /> Inspection Form Included: Q 2d l_`/C <br /> Comments Included: Q L 66 <br /> B s e ' 'gnatu a Phone Number lnspecto Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X4 q]jEjXjAjMjPjLjEj 11 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />