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Waste Tire Survey & Inspection Report -nspection Report Number <br /> Cal Recycle State of California 11 - 1177873 <br /> CalRecycle 181(Rev. (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- 1, � r n - o Inspection Type(Fill one) <br /> Site Suffix: 1 �p Ol• 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam \ oOuq wr. AA O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> su N ,,Lr s�� 3 q - l p , GS <br /> Physical Address n � <br /> LInspection Date 1 , <br /> Time In Time Out <br /> Business Rep Title ` 1 U • AM I ^ O 10 AM <br /> 0 0 PM oL 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � 5 <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed O Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair S Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder ® Other 1�/�efSV <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> ))Q.D� r (J�I�.Lc� U�llr(�1lL— <br /> - 1�ra��Aain U�CAs inotr�: <br /> 4�bt13 <br /> Inspection Form Included: Q q g <br /> Comments Included: 444h:2� - <br /> Business Re s Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: E X A 62081 <br /> 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CoLVA <br />