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Waste Tire Sur Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1242404 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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: Ll J 0 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local (_. ` C If Referral,choose referral type(Fill one) <br /> 5k <br /> Identifier: a CgL/lvl ��� Q CHP Q CalRecycle Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> J,�-mac", _ <br /> P �4�yy�hysi I ddress S ( Q t i4A/I ��f Q LL11 <br /> 1���� S , Glu,✓ 41L`�l °ham <br /> Inspection Date 3 / C <br /> C/t RS330 ( � <br /> Time In Time Out <br /> Business Rep Title ® AM ®AM <br /> 1 U O PM � l � � O PM <br /> l v�w11CiuS /�vt.G C' �+'I/�e, 1�CT� <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 ® Passenger (m Generator Outdoor <br /> O ® Closed O Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive O Truck <br /> Longitude - O PlannedOTR O End-Use O Container <br /> Business Type(Fill all that apply) �vC-y -C— <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler O 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 ® Other V� � t J f�ti 1 <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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Lu <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other:§ <br /> Comments C L <br /> Inspection Form Included: Q <br /> Comments Included: <br /> BuLeep's Signature Phone Number J sp_ t r /nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � E X A(M P LIE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />