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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1176698 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> - ------ -- - ------- ---- - <br /> Business Profile Inspection Details <br /> TPID- n 1 Inspection Type(Fill one) <br /> Site Suffix: 1 v —1 D I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sao do L'ti,f1 (0 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> lel A- W <br /> Physical Address <br /> C� /, ��� Inspection Date � ]� � Q <br /> v `-16 Time In v Time Out <br /> Business Rep Title 1 ( 10 l O PM 3 5 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passe ger Q Gen er foren Q Outdoor <br /> Closed Q AlteredIA <br /> GPS Latitude <br /> O Q Inactive Q Truck Q Hauler Q Indoor <br /> Longitude - Q Planned Q 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 Q Other WA <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING 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 / 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 EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 �ow��ncv kG�l 1 L , r D f\ I S - <br /> C�11D lA S n OA , r <br /> N o vi CAA, 16D-S 05)Cil. ("C-� - ( " can w n. f- <br /> `"zInkr`•�• C7ll��(1!1�� �5 LlOL�v�- �tw Vv'A'ntSS 1 5 JL4 Y , 11S S1e 'Dse <br /> Inspection Form Included: Q <br /> Comments Included: Q - -- - - - -- )f�t �Business Rep's Signature Phone Number Inspec is Signature Number <br /> - - 62081 <br /> INSTRUCTIONS ON BACK [C7orr�ect: Incorrect: X � EXVCC.PY <br /> 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pi © ■ <br />