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Waste Tire Sup Bey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242364 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA- Survey _____ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � l A � Q � Inspection Type(Fill one) <br /> Site Suffix: "l '* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �; Com Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 54g0, `Fire. svbe - 1 01 � �� -v <br /> Physical Address <br /> 117, 37 �; 1���r.w� 26 <br /> �`� C)-\ Inspection Date <br /> 9 SZ3C <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' 3 © 0P 5 0P <br /> '1�_\v0_"4C Nl -, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole��,��'F'1 t) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `-� ' ' l� o Active 4W Passenger ® Generator 0 OutdoorCo <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor1c!l� <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 /> Q 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 /> 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 EX7) <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 /> 2 <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 a In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments , <br /> Inspection Form Included: Q p� �!+ ��'�C��^C (,� <br /> Comments Included: � !�J-� I- d,�„-�1= 2(�-- "�_� <br /> usi Si t Phone Number nspec is Signa ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />