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Waste Tire Swe & Inspection Re oriblnspection Report Number <br /> CalRecycle State of California Y — ■ <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 11 — 1244927 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- F h 11 S " _ O Inspection Type(Fill one) <br /> Site Suffix: ` U "1 Li . Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- , 1 If Referral,choose referral type(Fill one) <br /> Identifier: S G n J O L111\ CC 1A n "1/� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 6 J <br /> Inspected By Inspector <br /> 1 l <br /> def `r1 tin `'�fCAN�Lr S Inc, <br /> Physical Address t 3 g O 1 C <br /> 355 Lr) <br /> lb O n C A r,S-)AInspection Date ' Q / 2 <br /> "1 Time In Time Out <br /> Business Rep Tiittle �,` O AM O AM <br /> lJ ® PM 3 0 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> * New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 16 Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 010 1 Other:§ <br /> Comments <br /> lnjq1 4 1A <br /> Inspection FormIncluded: 0 <br /> Comments Included: ®— <br /> Bu Hess Rep's Signature Phone Number Inspec 's Signature P one Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JE�XjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />