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Waste Tire Survey & Inspection Report ..=apection Report Number <br /> CalRecycle State of California 11 - 1177974 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Farm - 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- ` O - Q Inspection Type(Fill one) <br /> Site Suffix: t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: S(,((1�(� 1Mf1 l�lJ>�,� 1�1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> .J <br /> Business or Facility Name <br /> l L Inspected By Inspector <br /> � SS O U�\ed�- �f u,uT 0r � � I <br /> Physical Address (�-� D l Es_(Ar <br /> Ll <br /> Inspection Date t_7 / l / I <br /> r '"ISZDS <br /> Time In Time Out <br /> Business Rep Titles O 8 AM Q AM <br /> (7\.A\ (� l^f O 1�1 AI A O OL4b I ' \(,kt)Ct Cr 0 PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 9 p ) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ® Service Station Q Hauler Q Agriculture Q Shredder Q 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 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 /> 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 10 1 Other:§ <br /> a <br /> Comments \L04 w A li arc. ;n S 1 y <br /> 1 1 A v <br /> l-I <br /> — - <br /> No y tI o 1(9 ftS mf_ 64,Fe(A <br /> Inspection Form Included: Q, yy <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr Incorrect: IEIXIAIMIPILIEI 112 3 62081 <br /> ■ White C y:C I Yellow Copy:Operator Pink Copy:LEA ® ■ <br />