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M 02 Waste Tire Survey & Inspection Repon, Inspection Report Number . <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page 1 I1 - 1226509 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A= Survey BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- - m Inspection Type(Fill one) <br /> Site Suffix: V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: � ( �lr� COLL Q CHP Q CalRecycle Q Complaint <br /> Q Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> Wa,n� WY D�sAje. Foo�S Inc. <br /> Physic���I Address I 1 CS ISD <br /> Sao Inspection Date I 1 / Q / I <br /> Time In l Time Out <br /> Business Rep TitleO O O AM O O AM <br /> .` p 1 ® PM ® PM <br /> V <br /> M r fl S D U�Gtr D t�� �f e S I'� e Af --- -- <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 ® Generator Q Outdoor <br /> GPS Latitude D Q Closed Q Altered Q Hauler Q indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) o <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Q Notice Of Violation Q Extension <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 /> 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 EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 ®In Compliance-No Violations o <br /> Q Q Other:§ 11 " I I t <br /> Comments (ZOAAi l,L W C15L ' Yl I NKRVI �Il ung l�C��kj l� (/Lf�l'�, nn(A 411¢ U l J LI— <br /> �1 S A <br /> v� ' <br /> N o tj;f7j&k2,o^s aj ckrc 5 _t� cancarn- <br /> Inspection Form Included: Q -5 r6 <br /> Comments Included: -- - --- - - -��� 'O - � - -- <br /> _ s 's Ignature Phone Number -Insp or's Signature _ Phone Number <br /> INSTRUCTIONS BAC orr,ct ncorrect: l 1!7k EXAMPLE 1 2 3 62081 <br /> ■ White Copy: al ycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />