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M Waste Tire Su. ,rey & Inspection Report dnspection Report Number <br /> CalRecycle State of California Ila 1210204 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � _ � � Inspection Type(Fill one) <br /> Site Suffix: ! Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: ,n V Y_% <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ca v% -- )-ab Cil,���Y,: ck- C0Tw-'a ,oma -3 Ct - O 1 M)9\77 v <br /> Physical Address <br /> NIC) �OJV e <br /> Inspection Date - / 09 <br /> /� 9S33t� <br /> l.- Time In Time Out <br /> Business Rep Title O AM O AM <br /> �t 1t0.�C�C� S'tOC2S Cb��('0�\Q * PM Z , CJ 0 PM <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 /> • Active A Passenger 0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) irk <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Auto Body U Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ! Other Colncmkq- /Llan'34c�3re c <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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) <br /> Q 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 /> eu\� <br /> Ivd \-�—zaxa� 0V\S oc fr'�Gxs cx� - Cpy�C2CV_ <br /> z <br /> v , <br /> Inspection Form Included: Q ... kh A. -zc4-L169-3z94 <br /> Comments Included: • <br /> Business Rep's Signature hone Number *Insecto Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � jEjXjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />