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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1242542 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey _ <br /> Business Profile Inspection Details <br /> TPID- 0 4 9 .5 _ Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S ► Cc�til-� O CHP 0 CalRecycle 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �n Uk(rcA, ��ovi - 0 1 <br /> Physical Address esC'CMb <br /> m�f;�o��, P 1, <br /> Inspection Date L / -0 r_ <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' I ® PM ` S V PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active O Passenger ® Generator O Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive 10 Truck <br /> Longitude — O Planned ® OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) cult <br /> 0 New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other 1T� M;1eF l 1 )unbf,"J,ciu lel' <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 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) n <br /> Q 0 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 n i rw�? 1(cam i f15� Ab (Y.%:A'jS �� 1 C eA In v�1��i1�a� <br /> WVL�1i <br /> S <br /> No V11D1uA'i12..5 Or [Aj - s 64 (an(ern <br /> Inspection Form Included-0 � v ZLIR / 6=6 <br /> Comments Included:V (� `�00 b <br /> Busi s Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: _ � EXAM L E 1 12131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E4 <br />