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i <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1244933 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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- Inspection- Q Inspection Type(Fill one) <br /> Site Suffix: b S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(Av f,�(A1,1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ ' �J Inspected By Inspector <br /> `ll,10e, �Aa.0 <br /> Physical Address S 1i ] O , CS C V 7T1D <br /> Inspection Date <br /> Q-i 0 n C l� $3,40o J <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �Jll'C( C owncr ® PM 0 QPM <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 Ps e�� -1 ngger Q Generator Q Outdoor <br /> O ® Closed Q AI6d' 1" ' Q N <br /> GPS Latitude Q Hauler Indoo <br /> � <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 0 Other R2S�'a� a <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 /> Q Q 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 EX7) N <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 Q Other:§ 11 n <br /> Comments Zn%'G` wyc'L is 1 p OW� IL O7y /-S JbJ�C- :W` �Qd <br /> L �T��l. �nS C)T AICZAS�" & C )n(ePn_ <br /> 1. 0Wc �r.�Gcum>^ku aP� '�iJeS - S�U�h� rffs [w7L a [e,5il <br /> _NA jCA) CjCj,,�uP <br /> fe, 1v _ C Tft <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 7X_�_q11EjXjAjMjPjLjEj 11 2 3 62081 <br /> T <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CoyG% <br />