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Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1210422 <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- 1 Inspection Type(Fill one) <br /> Site Suffix: i p V "1 a ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ o JOU.,c ut ^ (DIA U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> 1 Inspected By Inspector <br /> Leas Sc Iwab ( 1 <br /> Physical Address 3 I Q C S C'0--r ' 0 <br /> vN, <br /> MaAV�C1k, CA 9:s3 31 Inspection Date g / O (_ / , 3 <br /> Time In Time Out <br /> Business Rep Title OAM O AM <br /> a. � QPM � Q � ® PM <br /> Q, M6 I'��i..so^ S . <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 /> .` • Active O Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR 0 End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Is Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 4D 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 /> 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 EXn <br /> a <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:§ <br /> Comments <br /> t Gt � r_D n �L (9.r��V 1 i � u 7 P cA.�ik <br /> �nVA U p = <br /> IV () 1( ]C)l Gt�T�b/15_ 1 T_�1�f 0-&4,6- V- ' -L;Q-n?.AF-f)- <br /> Inspection Form Included: Q <br /> Comments Included: ® f� <br /> Business e ' Signature Phone Number Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: Xli� q I I E X I A IM11 I L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />