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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California I 1 - 1245157 <br /> CalRecycle 181(Rev. (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 Inspection Type(Fill one) <br /> Site Suffix: , J 11 3 O ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.r1 �G v�,� (a_o O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business <br /> �CoorFacility Name Inspected By Inspector rn <br /> PhysiI�Cdi7ressC C1 <br /> S <br /> gSZIS Inspection Date 1 O / G / S <br /> Time In Time Out <br /> Business Rep Title ' 0 AM 2 ` h 0 AM <br /> G � O � PM J ` v � PM <br /> 7Q.w\2.s C17\e ��• S\jc. C• <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I* Active Q Passenger • Generator • Outdoor 3 <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 indoor 2-0 <br /> O Q Inactive .0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ! 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 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 EXE <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 is In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ��` CS 're- <br /> Inspection <br /> r <br /> �1 \ <br /> Inspection Form Included: Q 4 9 y g <br /> Comments Included: & N IP8 " �— 32g4 <br /> A-ness Rep's Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />