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Waste Tire Sur Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California j I 1 - 1230120 <br /> CalRecycle 181(Rev. (Ca 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- q Inspection Type(Fill one) <br /> Site Suffix: "7 6 1 0 Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 541An10a �1� �1,I n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> US Q, uwa - <br /> Physical Address 3 ( a 6_Sto ` 6 <br /> X33 �Oo,-<_Ii S Ri <br /> A aSz;�s Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> D. : O 0 ® PM U ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> /S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 0 Active Q Passenger Q Generator Q Outdoor <br /> 0 ® Closed Q Al1ef N l Q nddor <br /> GPS Latitude Q Haul r <br /> O Q Inactive Q 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 Q Other ' )IA <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ 7 <br /> Comments L'a 1 l I 1 1 N <br /> clJc.�s n o �0 i ( rn <br /> (� CA,-5- 1�u5 nss i nn 61 11f) DPe/ '\11\ �' g1�'e �t � is Gtr\ Q MJ-m lm b � <br /> Inspection Form Included: Q � , <br /> 46 t n3 17 <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK FCorrect-0 Incorrect: y � V E X A M RILX 111213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C p L ® ■ <br />