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M Waste Tire iftoy & Inspection Repol�pection Report Number <br /> Cal Recycle State of California 11 - 1176635 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Z 4 4 13 o ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � ,. , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> `► _ <br /> Physical Address kv, <br /> 3 <br /> 3 sv C-� -o P[ck,2-e, W c.L�) <br /> �J� Inspection Date (n�ft.i <br /> J CA �� 3a� 1 <br /> Time In Time Out <br /> Business Rep Title O AM r ® AM <br /> 1 d 3 © e PM t ( 3 O O PM <br /> ac:,e_l - <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 0 Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> LongitudeQ- Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 / 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 EXTJ 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 (6 In Compliance-No Violations o <br /> Q 1Q Other:§ <br /> Comments <br /> —_ b90-kH61 Q-0 Imp�-4 fit,r &AA4, 444d +r t.1 <br /> Inspection Form Included: Q v <br /> Comments Included: <br /> Businessep's Signet re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct. Incorrect: ; ( E X A L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />