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Waste Tire Survey & Inspection Reporti Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177854 <br /> CalRecycle 181(Rev. (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- _ © Inspection Type(Fill one) <br /> Site Suffix: * Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: an J Val IAA wu�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By ) Inspector <br /> LU1 Ve 1 fC.-S -1 <br /> Physical Address <br /> J TU(I-ves f1 <br /> Inspection Date <br /> (A " Time In Time Out <br /> Business Rep Title *� c O AM z O AM <br /> M <br /> 1 , u l �.11(l�J- <br /> \ J 8 PM J O a PM <br /> A Y11 r� l�t <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 /> 9 Active IS Passenger * Generator 9 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <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 /> _ New Tire Dealer &Auto Repair Q Trucking Fleet Q Government Q 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 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 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 <br /> Q r 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 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 Lo Other:§ <br /> Comments 1� r - I N �� S - 11` , S _L�_ t!( U U <br /> 1 t! w4X � L f <br /> Inspection Form Included: Q � Y�51 <br /> C-31 7 <br /> Comments Included: VL G <br /> usi aRep's Signature_ Phone Number &Inspleor's Signature Phone Number <br /> -- ---- - 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: A �� E X A t 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink py: © ■ <br /> \ r <br />