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Waste Tire Survey & Inspection Report Inspection Report Number � <br /> CalRecycle State of California 1 1 — 1 2 A v 1 <br /> CalRecycle 181(Rev.y(Cal S rvey Form m page 1 1 L `/TI L <br /> Dept.of Resources Recycling and Recovery(CalRecycle) VVV 6.9 <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t7 G q QI G O I Inspection Type(Fill one) <br /> Site Suffix: l J l ` 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �U �1 If Referral,choose referral type(Fill one) <br /> Identifier: (1�0 W LL111 1`� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> i <br /> NOJIAV1 �rnerl( A� Sp(� CIa���l� 1o4uc, r� - ) �SL� Q <br /> Physical Address \ ' �J <br /> Inspection Date I / (� <br /> to A, q �.�o <br /> Time In Time Out <br /> Business Rep Title 0 e ® AM 0 � AM <br /> J QPM I I � LJ QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) X/ <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> GPS Latitude O 0 Closed 0 Altered O Hauler 0 Indoor <br /> JA <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) (441 FL' lit- <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 PJC ?;Pc, (►77tnu�Kz u <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <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 /> 0 1 0 1 Other:§ <br /> Comments <br /> W Us <br /> yl u.f as &f co r)ccf n <br /> Inspection Form ncluded: <br /> 0 <br /> Comments Incuded: / I <br /> 79 <br /> B sines Signat Phone Number <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JEJXJAJMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />