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Waste Tire Su,vey & Inspection Report Inspection Report Number i <br /> CalRecycle State of California I 1 - 1210205 <br /> CalRecycle 181(Rev.y(Ca', 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- 1 � � � � � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J O Vv\, C 0 QV k Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Sok,,\V,Y, 3 9 - 1 AT T v <br /> Physical Address <br /> C A q S 33L Inspection Date / Q Z <br /> J Time In Time Out <br /> Business Rep M ` \ Title *AM r` O AM <br /> h 1M <br /> ft-� vla , � • -3 O Q PM o �J 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholePTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q ' ' g -7 9 1* Active i Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q 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 ! 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 I 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 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 <br /> Q Q Other:§ <br /> Comments <br /> CJ U \O`U. OVA OC kc-2GLS "Sj v— 0 <br /> Inspection Form Included: � �PW's <br /> Z�pZ f��J T� ^ <br /> Comments Included: Q 7 LY ` w0 I <br /> Bre Phone Number nspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: g EjXjAjM�PjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />