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Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1177814 <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- inspection <br /> e '^ I Inspection Type(Fill one) <br /> Site Suffix: �J 0 Routine 0 Re-inspection .0 Referral 0 Observation <br /> Local - / 1_ If Referral,choose referral type(Fill one) <br /> Identifier: �(�n J U(� l/�` l v un f 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> � Uk <br /> Physa Address <br /> V 1 ES C��Z7 <br /> 30�� LDUs�n� S <br /> YSabsInspection Date d, 3 <br /> Time In Time Out <br /> Business Rep _Title O AM O AM <br /> 0P 0P <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 Pas(sseenlgner 0 Generator 0 Outdoor <br /> G PS Latitude O 0 Closed 0 Alte-r�d^l 0 Hauler 0 inAWA door <br /> or <br /> 0 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 Nl� <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 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 EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years u) <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 <br /> in Compliance-No Violations o <br /> 0 1 0 Other:§ <br /> CommentsU (��„ Slt2, 1 1)!jg/e 1i .A + �tl���r`c,SS�i f)1) 6^ -C1' (ill I I�hl (» <br /> s����t '_Le llk- 01,EC.�t.mo_g'1 S1nQCS U-�1� se � y 6,21T1N1 AMAS - <br /> Wr.S (ins 4)1s "C �.p_ <br /> Inspection Form Included: 0 <br /> Comments Included: 0 �y -.. <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:10 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />