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® Waste Tire Sur '�.y & Inspection Report 'Spection Report Number <br /> Cal Recycle State of California 11 - 1176634, <br /> CalRecycle 181(Rev.y(clai 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- ) t r - Inspection Type(Fill one) <br /> Site Suffix: I �C ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 71Z� � C�y 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name j Inspected By Inspector <br /> A - I '��� 'q --T—, s _ <br /> Physical Address_ <br /> 7 <br /> 2-40Co 2 N W, ISon INC t j vel k� <br /> Inspection Date <br /> ��s Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> [� ) 0 ' f) d 0 PM 1 0 0 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 /> Y� 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Ni A <br /> 0 New Tire Dealer ® Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> - - --- - - - ----- - — 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years In <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 1Other:§ <br /> Comments <br /> --aAld 41, �fl I a.,,J "A_ <br /> WLc S C CA : -- - — <br /> Inspection Form Included: 0 X <br /> Comments Included: -- - 2c�r)L1�' 3 <br /> Busi ss Rep's gnatu Ph a mb spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: vN W ) ��EjXjAjMjPjLjEj 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />