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13142040194 <br /> Waste Tire Survey & Inspection Report Inspection Report Number . <br /> CalRecycle state c California(R I1 - 1186125 <br /> CalRecycle 181(Rev.y(Ca[ 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- ' / O Inspection Type(Fill one) <br /> Site Suffix: Z 71 ,5 rr/ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LLc�vv/'�[.ei �r✓2.��w I-rT l L�bj1 _ l 1 <br /> Physical Address O , 1010 <br /> Inspection Date U O <br /> City estate ZIP ode Time In Time Out <br /> Business Rep 1 TitleAM AM <br /> l f I 3 O PM ' ` O PM <br /> - <br /> Operational Status 'Tire Type'"' - Business Role 'Storage Type <br /> Tire Count(Whole/PTE) L� I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ;lilo� ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m . - Q Hauler Q Indoor <br /> O Q Inactive 0Truck <br /> Longitude – Q Planned ® OTR_Tj&Zlp Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 1b•.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 Q Other 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) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No violations o <br /> Q Q 1 Other:.§ L- <br /> Comments ; , OKI <br /> ,• N <br /> — D 1 io_ <br /> Inspection Form Included: Q <br /> ,�� —y25 �1Z3 So2� <br /> Comments Included: Q - - <br /> Busi e s Rep Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �� E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />