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Waste Tire Survey & Inspection Repot L Inspection Report Number <br /> CalRecycle State of California I 1 - 1177517 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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 cU O t Inspection Type(Fill one) <br /> Site Suffix: l� I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: Sal�1�d��{ (� CQunQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or^Facility Name` 1 Inspected By Inspector <br /> CAddy l�a q l� �S <br /> � <br /> Physicalal Address <br /> Inspection Date <br /> �. uk�)10 C �cS30 -11 <br /> Time In Time Out <br /> Business Rep Title (J C O AM O AM <br /> 1 J ® PM d 0 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Penger Q Generator�erator Q Outdoor <br /> O ® Closed Q Altered/ I V/ <br /> GPS Latitude Q Hauler Q Indo/X <br /> O Q Inactive Q 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 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 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§ (Required for NOV or EX7) - N <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> C §18461 -Manifest System Requirements for Waste Tire End-Use Facilities -jUL'R <br /> CR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations§ <br /> - t t J 4].V <br /> Comments �OtA1����, �1..jn i�Yr1.� JR. dr- {/�lS 1 LI-�LlU1,t�lM/1 <br /> 1 I <br /> N a 'j4()4WSn5 Dj 0-j�-t� AQACan- <br /> /-Ah O b <br /> Inspection Form Included: Q ! (��ry 319% <br /> Comments Included: Q Business Rep's Signature Phone Number Ins'torl'sature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: g E X AE 1 2 3 &A <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co5__ 1 <br />