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Waste Tire *ey & Inspection Repoi nspection Report Number <br /> Cal Recycle State of California 11 - 1176548 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ) T 2 2- 6 -7 a i ® Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: 1 0^nQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 p (;'-MP10+ 3 0 <br /> Physical-Address <br /> l 6 -4--1-1 k6'1) iuvild Rd <br /> Inspection Date � � / 3 f / <br /> � � r0 C/5 3�� Time In Time Out <br /> Business Rep Title O AM7 �j� O AM <br /> PM D o` T f� PM <br /> t0 C',� CSU �1"� 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 /> ®Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other A tif�oYte! S <br /> 1/14fZLCk L= . <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VAAHAU§HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> QWaste aTransport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 N <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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ow <br /> QQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q �:In Compliance ;;No PI tort ons o <br /> Other:§ c t <br /> Comments � LL ��, <br /> °V"_ Sy S 4 CIN`' _ �,ti i L 6�kC td6� n `d <br /> vLn�s� - <br /> Inspection Form Included: Q <br /> Comments Included: X 37, &Awj) L/6S—04 2.3 <br /> Business /p�Sign.ture' <br /> _Phone Number Inspector's Signature Phone Nbmber <br /> INSTRUCTIONS ON BACK Correct Incorrect. 62081 <br /> -- - - � � �IxIAIM �E �I2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />