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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California61( I 1 - 1230136 <br /> .. CalRecycle 161(Rev. <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- n Inspection Type(Fill one) <br /> Site Suffix: ' b 3 ( © I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local < If Referral,choose referral type(Fill one) <br /> Identifier: S 1,nZ0 al a1,q �jUU�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CLtfonv&krinl 3 q - 1 0 1 �S D <br /> Physical Address <br /> 300 E, V iC�or <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® Al i 0 ®AM <br /> 3 O PM I 1 LJ 0 O PM <br /> Jv��S� S�nonlern�� <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 /> Q Active Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude O ® Closed Q AIterA Q Hauler Q Indoor}Q <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 ®Other (71r�n1t7r�LT1�y��rry <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 Exr) N <br /> _ a <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 <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 1 Other:§ <br /> Comments Xn 44J W 14 bl./lJ' <br /> cso NOy1'(J&J" or aIW'S a-F -1_onzeFn_ <br /> ' Q u � �'JSP <br /> 1 cu�iw, �-u8 E.r� Lodi' '11 c nD o 7.rD. <br /> Inspection Form Included: <br /> Comments Included: (0Z.' a �? 1� <br /> iness Rep Signature hone Number Inspe 's Signature Phone Number <br /> INSTRUCTIONS ON 4CK C rrect:6 Incorrect: XA E X A P 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y:L © ■ <br />