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Waste Tire Sui vey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242467 <br /> CalRecycle 181(Rev. (Cal 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 Type(Fill one) <br /> OSite Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG1n J rN C(7tJ1�1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 10 � s 01-T <br /> "1s33 S. <br /> SiInspection Date <br /> a <br /> Time In Time Out <br /> Business Rep Title c AMAM <br /> ^� '` 1 10 J Q PM 0 Q PM <br /> OU t" F�r►2�1�� uvt.0 <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 /> Is Active Q Passenger ® Generator Q Outdoor <br /> Latitude O Q Closed Q Altered 1J)A <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) UJ <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 9 Other wfAd*Ajc,,Ase_ <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 101 Q Other:§ <br /> Commentsnf✓ W u I� <br /> �Ov�� s�e. �1 ln��u� 110"19-- 0^46.1 <br /> nAI LA)LAS DOC e-(�= <br /> Inspection Form Included: Q , <br /> Comments Included: S %N� D lei -'11-73 '31'1 <br /> Bu ness Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: :XE X A M 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />