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4 <br /> Waste Tire SL.,vey & Inspection Repon, Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226527 <br /> CalRecycle 181(Rev. (Cal 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- 0 C - C Inspection Type(Fill one) <br /> Site Suffix: 1 J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: SAA J UCtJ Ciro (011-a � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> CU � <br /> (� nal LaIIA''o _ /1 <br /> Physical Address l G V ( Cs LU <br /> Lu�Y) l.� <br /> l_ roC � °1533U Inspection Date <br /> P <br /> Time In Time Out <br /> Business Rep Title j� 0 AM C 0 AM <br /> ' (J ® PM _s <br /> ® PM <br /> 6_2%1n f D -- <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 Q Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered � 1 v 1A <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®'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 ® 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 <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 /> 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> ujuj <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ I / <br /> Comments IC fl L.Tf1 Wei sv �� 1 n1�-0ll JW OA IfsJ, wn <br /> / LI )�tLfr? G�r1 l <br /> "vim <br /> Inspection Form Included: Q <br /> Comments Included: 0 -- -->`-����� J��r��—+► <br /> sine a 's Si nature Pf�one Number Ins tor's Si nature Phone Number <br /> P P 9 <br /> 62081 <br /> INSTRUCTIONS ON ACK Correct: Incorrect: tz\ � q EXAM P 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:VE © ■ <br />