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Waste Tire Su. vey & Inspection Report Inspection Repor"Number ■ <br /> CalRecycle State of California Il - 1176739 <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- t 1 G © ( Inspection Type(Fill one) <br /> Site Suffix: "1 ` f ®Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: Sa� C� LII IN Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Q\'k c,2� <br /> Physical Address <br /> •1 �53�� Inspection Date <br /> Time In Time Out <br /> Business Re\p,� Title - O AM LA Q r O AM <br /> 0)�1�n�_ �Q. ---® PM `� 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ` (6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` • Active ® Passenger Generator Is Outdoor <br /> O Q Closed Q Altered <br /> PS Latitude Q Hauler ® Indoor <br /> OQ Inactive A Truck\[G <br /> i Longitude - Q Planned ® OTR Q End-Use Q 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 ®OtherPool �Uatlt <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 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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 <br /> In Compliance-No Violations o <br /> Q Q Other: <br /> Comments <br /> Inspection Form�nC <br /> ncluded: Q <br /> Comments luded:-S - <br /> Business hep's SkAture Phone Number Inspec 's Signature P one Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �jEjXjAjM19 LIE 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co ■ <br />