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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242334 <br /> CalRecycle 181(Rev. (Cal S���r/ey Firm - 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- � ` , � �� � � � O � Inspection Type(Fill one) <br /> Site Suffix: 1't is Routine Q Re-inspection Q Referral Q Observation <br /> Local �' f If Referral,choose referral type(Fill one) <br /> Identifier: S G� J Q u Q 1. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> ES� sin Log' ` <br /> Physical Address l , J�,CS ) _1—(, 3 I — 1 0 1 CS(_0'TTb <br /> \$100 S_ H e4d &t oQ6�. <br /> Inspection Date °7 / l T7 / I <br /> L.�'�� Q C A �5 33D Time In Time Out <br /> Business Rep Title u ® AM AM <br /> L ' { S 0 PM o 0 PM <br /> SZ'1 e mu,nrti � - - <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 /> I#Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered ' A <br /> GPS Latitude Q Hauler Q In )door <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR 0 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 .0 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 <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 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / F <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ _ <br /> Comments 1 <br /> t � <br /> u <br /> Inspection Form Included: <br /> Comments Included: S <br /> usmess Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: **Y: E X A 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />