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Waste Tire SOey & Inspection Reportolnspection Report Number <br /> CalRecycle State of California81( I 1 - 1230339 <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 I Inspection Details <br /> TPID- 1 O inspection Type(Fill one) <br /> Site Suffix: I , e Routine Q Re-inspection Q Referral Q Observation <br /> Local //` ] If Referral,choose referral type(Fill one) <br /> Identifier: SQn JO 0,y L4,I'n lx91AC) � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> P Inspected By Inspector <br /> �_ A- v 4Sf1S�\ 4- SUn .�J1G, <br /> Physical Address 3 q <br /> _ to 05 Gn7so <br /> Lino N . wi,ko , Um <br /> Seo ��+O n c A (; s�(/L�CU Inspection Date <br /> �l Time In Time Out <br /> Business Rep Title O AM u O AM <br /> �d�� �'�r fGSS Aly ►1(l J � � PM � ` 5 �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 /> Q Active 0 Passenger Generator Q Outdoor <br /> PS Latitude <br /> O Q Closed Q Altered NIA <br /> G Q Hauler Q Indoor <br /> O ® Inactive ® 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 L <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 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 n <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 ®In Compliance-No Violations o <br /> Q Q Other: ,{1 1 <br /> Comments ,/T ` , 1 I r J 1 +1\0_ 4011 <br /> 1 . , __111_1 ] <br /> UTA��(,I,S�"e.��1Q.1 -�,S�Pd�i lL� t, C.t.�%A 1 `y� U I It%4� <br /> 1)c) yiola�'un& y3 utatAsy»»>> 'C Ce,rn - <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> �-,( <br /> X NJ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM LE Ll 2 3 1 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:LFA <br />