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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state of cleCalifornia811 - 1230335 <br /> CalRecycle 181(Rev.y(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- O _ Inspection Type(Fill one) <br /> Site Suffix: O I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sart Zoa' � : � (otk Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or`Facility <br /> yNName Inspected By Inspector <br /> Physical Address Q CS CO-TT (� <br /> 3'1 3n N • W;�5(y, liVu� <br /> Inspection Date 3 � , a / � S <br /> Time In Time Out <br /> Business Rep ([�� Title O 9 AM l c O AM <br /> VeQ PM 0 PM <br /> r01� 11JSu�1n�-� �`„��er ( + <br /> Operational Status Tire Type Business Role Storage Type <br /> ' <br /> Tire Count(Whole/PTE) 1' Q T] V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active ® Passenger Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Hauler Q Indoor <br /> O Q Inactive S Truck <br /> Longitude - Q Planned 0 OTR ® End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 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 /> ®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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m I / <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) N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 Q In Compliance-No Violations o <br /> Q Q <br /> Other:§ <br /> Comments 1C�tJ ny�.L� �•�13c. 1 ape[ � U� S Q�—C�(�(� `(�`�- �Q�LO'W' <br /> G S n <br /> Inspection Form Included: � v C �� � <br /> r �4-317 n <br /> 3 <br /> Comments Included: ®—flusiness Rep's Signature Phone Number Inspec o 's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />