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0 Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle 181(Rev. <br /> R I 1 - 1196386 <br /> CalRecycle181(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' 1 © 1 Inspection Type(Fill one) <br /> Site Suffix: "1 l0 • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: Sall JQU G UtVN ���,��tJ( 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L �J <br /> Inspected By Inspector <br /> Fe CaG� 6sV0fc,�V;0__\ 3 — l U ES CU b <br /> Physical Address <br /> Inspection Date � / 0 <br /> Time In Time Out <br /> Business Rep 111 Title O AMAM <br /> nt C� V61. 1 9�G1.�1t s' [ 0 ® PM � � t.l 0 PM <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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O ® Closed 0 AI IA 0/14 OM <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other N <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> t4-eeR§1845"-=Retenkiorr-of-Eomprehensive-Trip Logs-for-3-yeam -- — <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 101 0 1 Other:§ <br /> � ' 1 C-' - l-- z <br /> Comments t-o�NL W(MiL 'R`Q- i n5oP 6^ ADM- 9-N�+"l-)'S �J1IL C4+rl� <br /> V� ek S �1�C j 9_ <br /> �FN414,„ \ai&S lnui (A NI _AQ L4 0A.AM�a�a; <br /> S 1'l`72lU —U 011 (L V- °I6z 77, Clb ` 1ilsTPSD. <br /> Inspection Form Included: 0 g <br /> Comments Included: 0 �Z Z t)i 0vv <br /> 31'7 <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK I Correct:• Incorrect: E I X I A I M I P I L I E I 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />