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Waste Tire Su, vey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of California I 1 - 1176440 <br /> CalRecycle 181(Rev.y(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 Type(Fill one) <br /> Site Suffix: I Lj Lt t e Routine Q Re-inspection Q Referral Q Observation <br /> Local /� �, If Referral,choose referral type(Fill one) <br /> Identifier: SCl.V1 ��>( �n� C�C�t/YL' �l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namey ll <br /> Inspected By Inspector <br /> �o� C:v�n l 39 - O A l6.5-y Arum kwlc.1 <br /> Physical ddress <br /> &b_ S ' 'Ac",Ivl Sit-. <br /> L A r 7 `Inspection Date '�7 / Q <br /> C�I'L t l.0 CC', / �JTime In Time Out <br /> Business Rep Title _ 0 AM 0 AM <br /> OL - 0 d ® PPA 0Z � +� *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 ail that apply) <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> Latitude D ® Closed Q Altered� Q Hauler Q indoor GpS PS <br /> O Q Inactive Q Truck <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 ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 A <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ll�I <br /> X101 ln� rh So���4 t�v. n e P rneir C" -- ,H 6CA r d I, L},G t c i�10, s Cre— <br /> te_c <br /> r - <br /> te_c -27y/x Fn c..; <br /> \ V ' AW r ZYMMn <br /> 'TU�LY� '440l be, GLO�c'�C� <br /> Inspection Form Included: Q <br /> fACComments Included: Q "l X6;7 <br /> Business Rep's Signature r Phone Number 1 I ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E A ' L 11213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co Q <br /> ® 0 <br />