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Waste Tire SL. jey & Inspection Report inspection Report Number <br /> cle State of California <br /> CalRecycle _ <br /> Y CalRecycle 181(Rev. (C Survey Form - Page 1 I1 1177836 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details — <br /> TPID- _70 1 1 Inspection Type(Fill one) <br /> Site Suffix: U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SUS JO" V h Url Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M4ZA„,N c5a(}- �t`oc�.vc�S _ o <br /> Physical Address <br /> 262 <br /> 0.0 cA Q J <br /> S 2'7.& Inspection Date <br /> Y q537.& <br /> ! Time In Time Out <br /> Business Rep( Title O AM 3 O AM <br /> 2 S 0 PM ® 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 /> ® Active Q Passenger ® Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive I* 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 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle A <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q_0 Other:§ <br /> Comments y 'k- asO'V'-x der_ f'vhe-C\ 01n <br /> CA, V, �-�e l a vs Y\,� ct.s c's VVG ke <br /> oc Gre_CXS con.ctriel <br /> Inspection Form Include �2. � <br /> Comments Included: ��� AAJ (C20q) �� / <br /> Business Rep'sV*gat re Phone Number nsp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L1 111213162081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L © ■ <br />