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02 Waste Tire Sup vey & Inspection Re <br /> ortOnspection Report Number <br /> State of California <br /> CalRecycle 181(Rev.y(Ca)' Survey Form - Page 1 I 1 - 1242310 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I r Q 1 h _ Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sq(\jdU LI� Gil Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name �t Inspected By Inspector <br /> Physical Address l Q CS Q)TTO <br /> Inspection Date l7 V I <br /> M U� � c� s3310 <br /> Time In Time <br /> Out <br /> Business Rep Title 3 O AM (� O AM <br /> ® PM V #j PM <br /> SUt: L�Uc Ccs., �pki vn�SI' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 13 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' o a Active di Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <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 /> ® New Tire Dealer 8 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 <br /> 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 / [—n <br /> / 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 n <br /> 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 /> f <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 41' <br /> 4 �l 9 ' A 7 <br /> C )\k)1 A 11 nl� 1_al U`S n a 1 c/j ' <br /> No Nl 04Wb-IS of CAAC 4> O� <br /> Inspection Form Included• {I^ <br /> Comments Included: 1 'U <br /> '�6epSignature Phon Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: (� E X A L � 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L �� <br />