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Waste Tire SWy & Inspection Repormspection Report Number <br /> Cal Recycle State of California 11 - 1176433 <br /> CalRecycle 181(Rev.y(CalRecycle) 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: ( 5 S- Z -9 l, Z <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M A ";c _ <br /> Physical Address-0 <br /> /tyvlGoLZG�Gi L�C�"✓��� <br /> Inspection Date Q <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 1 2 • 1 0 ® PM C, © Q ® PM <br /> / Yc� Soh ��wner <br /> - 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 /> Z 2 ® Active Q Passenger ® Generator a Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor' <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q 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 /> 18 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 41 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 /> ....__.....-_-... __ _--1 Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport 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 / Ffl / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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:§ <br /> Comments <br /> �/� <br /> /�'CON.AX1 Inc g�c� > `7�?aZ.t ���.;��. C�.,c/ �s� 4 �,r�,•c., ,� <br /> ZA,/- jr 14a fry- - <br /> Inspection Form Included: 0 J G (� <br /> Comments Included: 0- r,?o`1�H S° "moi ��� ..tee z eej y ff—062 <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ><' X A I P L 1 2 3 62081 <br /> --- <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co A <br />