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Waste Tire Sui vey & Inspection Repon Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1177828 <br /> CalRecycle 181(Rev. <br /> (CO) 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- Inspection Inspection Type(Fill one) <br /> Site Suffix: L4 1 `7J Q Routine Q Re-inspection Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: &An jo"LLl n U, Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "_ Inspected By Inspector <br /> Physical Address CC11 I ScD�U <br /> �4b 5 S. HAr f r'S!�/� HJT, """""" <br /> /f, VrN C� ��� Inspection Date � / 0 -7 / 13 <br /> �10!"�" Time In Time Out <br /> Business Rep TitleO AM O AM <br /> I S S (a PM oZ U & PM <br /> I 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 /> Q Active Q Passenger Q Generator Q <br /> / Outdoor <br /> PSLatitude o • Closed Q Alter d ' V AGQTrA Q Hauler Q Indoor <br /> 0Q Inactive uck /� <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 /> 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 Q Other I V A <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 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 3 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 lr_) Ilrf I^ a h n,L c7•. V11 S Q�t(1�'v Ob�1 rLl� T���.DL�� <br /> f <br /> o U,vl ti�fV,Soff' - <br /> 1� o�eS•. 1_ Vazt(A 't�\ Inn �0ti �T 4+ '�'�Yt's <br /> 5� dose, -fPTQ., <br /> Inspection Form Included: Q % - (�,l <br /> Comments Included: Q � ' <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: M EXAMPLE( 1 12 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />