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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196530 <br /> CalRecycle 181(Rev. (cal 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- Inspection� � � o � Inspection Type(Fill one) <br /> � Z <br /> Site Suffix: I • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Sir J O CLQ V kV\ Co V �• / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physic s Address <br /> C�: d� '��-�c� G `S c�:,��c �eea.c y _ d M A�fi -70P <br /> 1022. <br /> Inspection Date <br /> s / / 4 <br /> ;ed�n C' 366 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> e. 0 PM L * PM <br /> JcSs�. <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active Q Passenger 4& Generator 0 Outdoor <br /> - O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 0 Other 'rV'0.a\.e` y t %(_ <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 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 F11 / / 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 <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 /> 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 <br /> Q Q Other:§ <br /> Comments Z �� <br /> C�\. c b S\ vNe �S—\ ^ N <br /> 'p—A, V1 `S <br /> 6 v��a C knea v'ceM <br /> Inspection Form Included: . ��/pp (� <br /> Comments Included: '� q"Wo�3Zg 1 <br /> siness s Signature Phone Number Inspe or's Signature _ Phone Number <br /> INSTRUCTION ON BACK Correct: Incorrect: :X:CV::]j E X A M P I Ll El 1 1 2_L3162081 362081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />