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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1242464 <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- Inspection_ O Inspection Type(Fill one) <br /> Site Suffix: 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local �\\�44 I r If Referral,choose referral type(Fill one) <br /> Identifier: Uel �J"LL1IN `U u�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> G e-tkr"\-Q,Lk,cke, �o�e�G�,2. S1 iDp <br /> Physical Address G <br /> \to Sem4e <br /> c.� C!� <br /> Inspection Date d <br /> an�e �tS337 CJ 1 <br /> Time In Time Out <br /> Business Rep Title 1 I 11 0 ® AM AM <br /> l 1 0 PM 5 O 0 PM <br /> n inner <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 Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) (Y1 )-,qpi L <br /> Q New Tire Dealer 0 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 ® Other fn4oya G� apor <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 <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 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 pp <br /> tri 7 i'1� j 4n til, l 1'+I <br /> 1a- <br /> N V M C)V11,0^& 01 L+ 1 eft , <TJ C L-A e rn- <br /> Inspection Form Included: Q �7-� q �� 1 <br /> Comments Included. ® " _ 6_ I7 9 <br /> Business Rep's Signature Phone Number Ins tors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® 0 <br />