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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1230315 <br /> CalRecycle 181(Rev. (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- n Q I _ Q ( Inspection Type(Fill one) <br /> Site Suffix: O( ` ! 0 Routine Q Re-inspection Q Referral Q Observation <br /> Locali (MA <br /> � ��� If Referral,choose referral type(Fill one) <br /> Identifier: SOA D 1�t 1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 16;a� ,nr)&, Q�.} Fa�as Q _ r <br /> Physical Address t Q l l�5 W'��o <br /> 'X o� vn Ave. <br /> A - <br /> CL� <br /> Inspection Date / o 9°I53�� <br /> Time In Time Out <br /> Business Rep Title n Cj 0 <br /> 0 AM 0 AM <br /> ( � PM ® PM <br /> Som �'16��-f s,��'� m��. oL <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 /> 21, • Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude 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) UT <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 p 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other Oli(XA 1 100051,,jr �`C14 <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 / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> Q Q Other: <br /> Comments <br /> iv 1 Wt- t7 J <br /> Inspection Form Included: Q <br /> Comments Included. ''' <br /> Business Rep's Signature Phone Number In ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ] EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop LEA © 0 <br />