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Waste Tire S.. vey & Inspection Repo Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242227 <br /> ry <br /> CalRecycle 187(Rev. y(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 Type(Fill one) <br /> a <br /> Site Suffix: 3 -l 8 8 ' 0 ( 8 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: v� ,fX.���\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> p'I K � 3 <br /> Physical Addres l O 1 AKA✓ll 13 ULA <br /> 1500 404_�C_ <br /> Inspection Date � / O � / I G/ <br /> �„-�, G14 gs�3c7 <br /> Time In Time Out <br /> Business Rep Title r� O AM O AM <br /> /9l� 1�(Gt rlAaCi.� of- ' PM 2 (( *PM <br /> lY V�w1N_ <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 /> ® Active Q Passenger I*Generator Q Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered -At/ <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned • 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 . Other <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 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 <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 EXT) N <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 /> f <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 �J <br /> JCG NI'M? P N <br /> Inspection Form Included: <br /> Comments Included: "k2 <br /> us' ess Rep's Signature Phone Number F4­pe-/t­9r,*%'iq,7ature Phone Number <br /> .1 1 <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: M A EXAM 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />