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03 Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177611 <br /> CalRecycle 181(Rev. 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- t t 2 O _ O inspection Type(Fill one) <br /> Site Suffix: I 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: V�r, CO u n,�-J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address C5 1 <br /> I`6 300 S. Nctc la,n 1"2c�- <br /> Inspection Date � / � � / I <br /> t--0.` C'o� CA q .5 33 2 Time In <br /> Business Rep Title 1 � 0 AM Time Out (i AM <br /> { <br /> C1.V, C) wF-11 4e>t'Ce- mokrjf.0 41 PM OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �( (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> CEJ ® Active Q Passenger `Generator Q Outdoor <br /> GPS o Latitude Q Closed Q Altered N/A <br /> Q Hauler Q Indoor <br /> O Q Inactive 0 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 0 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q 1Other:§ `` 11 ^ -Y ` 1 <br /> Comments A�_s c d Y% Mn.zs [t��.a ke co,r� Mn e <br /> r I� 1 � <br /> O�-LQI J (� �J QS�/1b'Ce <br /> Inspection Form Included: Q ,`p <br /> Comments Included: X/_ <br /> ' - � ��,((ia �3Zgy <br /> Busss Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> 1.11 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />