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Waste Tire Sul ey & Inspection Repo Anspection Report Number <br /> CalRecycle State of California81( 11 - 1255841 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` 6- Z <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local �. If Referral,choose referral type(Fill one) <br /> Identifier: <br /> w\ JC> V\� f � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Y <br /> Inspected By Inspector <br /> Physical Address n ,, A� <br /> `L2,�7 ���°' S �^ lVl <br /> Inspection Date 0 J / Z 1 / 16 <br /> Time In / Time Out 1 <br /> Business Rep Title r0 AM 0 AM <br /> 1 <br /> ' • � 0 * PM -2, : V * PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whale/PTE) Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator ! Outdoor <br /> GPS Latitude O O Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive I* Truck <br /> Longitude - <br /> • Q Planned Q.OTR . O End-Use O Container <br /> Business Type(Fill all that apply) <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 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 PRC§42951.-Waste Tire Hauler Registration and Transport of Tires <br /> Q . 0 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 <br /> QQ 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 o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Referred/CalRecycle Enforcement <br /> E <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> N( oy �a,�^or.5 ® ` cep- G�- Co►1ce('✓\ . <br /> Inspection Form Included: Q Q -n,3Zo <br /> Comments Included: 0 <br /> &nes,R p ignature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />