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1 <br /> Waste Tire SL. ✓ey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226585 <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- I I I - 1 Inspection Type(Fill one) <br /> Site Suffix: ` Il ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalCO <br /> ' L If Referral,choose referral type(Fill one) <br /> Identifier: S n �oul q 1 l O14 Yl'Ll� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` 1 <br /> I— <br /> fo <br /> Inspected By Inspector <br /> I�b n �� <br /> Physical Address I E Cf) C—St A p <br /> Inspection Date I () / I r� / l 1 <br /> aaLkD CA °l S zo3 <br /> Time In Time Out <br /> Business Rep, `` Title S 10 AM ,l 0 0 AM <br /> ` P�'Uf1tc• 1(.p f AA �f;n- ASSlz✓ - 0 PM U O PM <br /> V b-2 Sl(Y'►1 �C-[�Pl fit,( � (. <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 ® Passenger ® Generator (a Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR End-Use ® 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 f Other ►1 ►j�1 1 (Cul-11 I <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 / 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 EX7) <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 u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r <br /> •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ��jj 111 11 <br /> 1<l�1�1h e IA)11-4- �,1�-�nsQCJ,y11 OU)CV- (�In �'1) S L"I'e, Ctfld`y'{11 <br /> V 40 1�Wlflfil <br /> y 5 <br /> i 4�1 S (c S anco-rn. <br /> Inspection Form Included:( <br /> "1 f - 3�� <br /> Comments Included: — .�- I� <br /> - --- - -- <br /> usiness Re 's Signature Phone Number Inspe is Signatur Phone Number <br /> � <br /> INSTRUCTIONS ON BACK Corr t: Incorrect: % (� E X A M E 112 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L © . <br />