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I 1 {, <br /> 2 Waste Tire Ste, vey & Inspection Report ' Inspection Report Number ■ <br /> Cal Rec cle State of California — <br /> 1226528 <br /> Y CalRecycle 181(Rev. (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I1 <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t j O - I Inspection Type(Fill one) <br /> Site Suffix: t I * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: UA 3-0 ^ �td fl lV� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> Physl I Address LD <br /> a5 3 -1 eA, <br /> (A g 5 z0 S Inspection Date I 0 � � � / I <br /> fl G �D n Time In Time Out <br /> Business Rep Title 1 (,{ e AM �j O AM <br /> ' I Q PM f ✓ ® PM <br /> -11� r k�A h Ower <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0_5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 /> ® 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 <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 ®In Compliance-No Violations o <br /> Q Q Other:§ I <br /> Comments 1(ll 1 q� <br /> Inspection Form Included: Q <br /> Comments Included: ® '.k - ��f•4 .gS7o _ c- 9&..— <br /> Business Rep's Signature_ Phone Number Inspe&tr's Signatur Phone(X Number <br /> n <br /> INSTRUCTIONS ON BACK Correct:49 Incorrect: \� E X'A 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y, © 0 <br />