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0 Waste Tire Sup vey & Inspection Repori Inspection Report Number <br /> CalRecycle State of California 11 - 1177606 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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 r n O ` Inspection Type(Fill one) <br /> Site Suffix: �O -1 I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Cllr J 0C ot kt n 0-vtnQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> � <br /> �r _ <br /> PhysicaCIddress��7cI O , ESC�T� Q <br /> CA `��zo5 <br /> Inspection Date _ / 1 -3 <br /> I <br /> Time In Time Out <br /> Business Rep Title j `- ( ) ® AM l ® AM <br /> l Q PM 1 0 PM <br /> NJ Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 5 a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q 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 ® 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 <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 <br /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 /> LU <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 1 Q 1 Other:(§ <br /> Comments TUU ' 4 wUl L 1 j l� 1 e%Cin 3 ��s <br /> N 1�6OAA'V) 1 EACs f)(*cU; <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> I ss Rep's Signature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7X*_V]jEjXjAjMjAL11213162081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />