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0 Ml * ste Tire Su. rey & Inspection Reporli. Inspection Report Number <br /> cal6ecycle State of California A I 1 - 1210 318 <br /> CalRecycle 161(Rev.y(Ca SUrvay Fovrn - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) �+M <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 b CO - Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa,n J CO A- <br /> 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name { Inspected By Inspector <br /> _ t <br /> Physical Address C) <br /> -Z9 A S Fce_^C r' <br /> Inspection Date 6 / 1 I / I 3 <br /> Manke.co� CX 9 5 33� <br /> Time In Time Out <br /> Business Rep `` Title, ' 1 Q * AM ^ *AM <br /> r)Q MO�C'Ghlh\ J it�'l p`(— o PM \/ Q PM <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 /> 40-Active Q Passenger ! Generator Q Outdoor <br /> O Q Closed Q Altered N/A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40Truck <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 • 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <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® / ` 3 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> N / <br /> (Required for NOV or EX n <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> _ a <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments VC7 O'S P-r Ck"t, ^ A01ne 0y\ <br /> Inspection Form Included: O 4k-328 H <br /> RgZ-o8� Zoq- <br /> Comments Included: 'C9 — <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> _4___]jjjjjjj <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: X EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />