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2 Waste Tire SL- ,✓ey & Inspection Report Inspection Report Number <br /> Cal Recycle State of CaliforniaI 1 - 1177875 <br /> ry <br /> CalRecycle 181(Rev.y(Ca(CalRSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recoveecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1, ry ` 4 1,I Inspection Type(Fill one) <br /> ", 1 <br /> Site Suffix: i d I O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: an J00_lwn I.ouoi! l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> � 1 <br /> Business or Facility Name Inspected By Inspector <br /> Co Y, �)S� s _ ��rt cam. <br /> Physical Address G C S <br /> TInspection Date l a / 1 / 1 2 <br /> c�.c,v� °I S3'��O <br /> Time In Time Out <br /> Business Rep Titler) O AM O AM <br /> 3 O U <br /> 40 PM ® PM <br /> n WAll IT <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 /> ® Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — ® OTR Q End Use Container <br /> Q Planned <br /> Business Type(Fill all that apply) <br /> �J New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 4k 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 /> 0 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 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments uC, t t� n �S &k a 16N c� <br /> Inspection Form Included: Q <br /> Comments Included: h y <br /> Business Rep's Signat re Phone Number Inspe is Signature 15hone Number <br /> __0�INSTRUCTIONS ON BACK Correct: Incorrect: X g� E X A L E 1 2 3 62081 <br /> JJJ® White Copy:CalRecycle Yellow Copy:Operator Pin <br />