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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state of California 11 - 1226337 <br /> CalRecycle 181(Rev. (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- ' n n U - 0 Inspection Type(Fill one) <br /> Site Suffix: `� dr ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: �Cl(1 �(�(1��(,(1^ C(91�1 n Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CS�ensor\ L o� i s�-;c s LLL 3 h <br /> Physical Address V 1 C <br /> Inspection Date -2) <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM ® PM <br /> (Yla��. C t.�w�+►�� 5��� rn c <br /> - - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) , f (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> O Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 40 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 <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 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 /> Q Q 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) N <br /> a <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 /> LU <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 ; �L �lSt 1nSC"Xit r1uze_ U11 A5 (ALcL Gn(A fim , <br /> 7 <br /> -- 0 ca' L <br /> Inspection Form Included: Q <br /> Comments Included.- 9 <br /> Business Rep's Signature Phone Number Inspe or's Signature - Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P _ 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L A ® 0 <br />