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r <br /> Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle California I 1 - 1210445 <br /> CalRecycle 181(Rev.ycal 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 Type(Fill one) <br /> Site Suffix: v Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SU�>1 J 0 u I JA;n C V I&nk'-tA Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> /fn� / <br /> Physical Address 3 o 0i l CSC -CT Q <br /> Inspection Date <br /> o�4L��n C� �ISZbS VV I <br /> Time In Time Out <br /> Business Rep Title e�- '� : -,?3 V O AM : O AM <br /> SOS 1 S �1APM -C ® 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude <br /> O ® Closed Q Att�tA Q HaulNIerA Q Indoor rN <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> 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 /> 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 EXE <br /> a <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 o <br /> Q 1 Q 1 Other:§ <br /> Comments P A ' ' 1 �. 15�g f N <br /> 4Z b£R.s x1-'1'Mu)_d- <br /> ��- — <br /> l� <br /> 11 d- � l s Sri 10 1I R , <br /> Inspection Form Included: Q y /! 1 <br /> Comments Included: Q"...ine.. <br /> ���Ll(A <br /> p's Signature Phone Number Insp or's Signature v <br /> Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: q �jEjXjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA, <br />