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Waste Tire St iey & Inspection Repor' Inspection Report:Number ■ <br /> CalRecycle State of CaliforniaI 1 - 1177587 <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- CA O Inspection Type(Fill one) <br /> U <br /> Site Suffix: ` _` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r-- If Referral,choose referral type(Fill one) <br /> Identifier: J a V; � y��1./ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> St"\ seri <br /> Physical Ad�fressO T` - �`� '`f� <br /> 515 ► 5. A- reocV a� <br /> ` 2a6 Inspection Date � <br /> 5 cvvo� I S Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM © PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> r/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �[�' <br /> ® Active Q Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered AJ I <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Ppo'li <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 40 Other 5�e4 <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 /> 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.1 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> a� fL Vl..,c> W�4-'s NA CAP <br /> A) V�o����cry� _r� 0.r e&S 0 Co v�-C e C Y\� <br /> Inspection Form Included: Q A01 9` q-10#d I <br /> A49- Zc�9-46g-3i8�1 <br /> Comments Included: <br /> usiness el s Signature Phone Number Ins�pd or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �EjXLAj& PjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator P' Copy:L © ■ <br />