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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of cleCalifornia1(R 11 - 1230067 <br /> CalRecycle181(Rev.Recovery <br /> 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- I � 5 - 0 1 Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5CL ,.� /y Y\- (0 k) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Co V-%'X U_-) erOv\a as <br /> Physical Address 3c[ - <br /> �S�S S• Ft 9017611c� SA-. <br /> SInspection Date C) G / S <br /> S Y) Time In Time Out <br /> Business Rep Titlep fl�� 0 AM 10 AM <br /> 0 PM Q PM <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 /> O XACI:sqrA- <br /> Q Passenger Q Generator Q Outdoor <br /> Latitude CIO Q Altered. QGPS la(ure1njJ/.kr <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 Q 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 EXE <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 /> 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 1 Q Other:§ <br /> Comments + L'51 �`( h <br /> I�_j cco v��u. ovayc esILS c - Coir`.e Y\. <br /> Co 5:,X \,��ot �� c c,�S \orc2( Ca ^S Ca C pl(�. P_s.J <br /> �leC <br /> Inspection Form Included: Q <br /> Comments Included: Q -- — J <br /> ElUsiness Rep's Signature Phone Number Inspecto s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E�X�AJMJP � LJEJ 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />