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Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1210468 <br /> CalRecycle 181(Rev. (Ca), Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- A3 O C7 O 1 _ © Inspection Type(Fill one) <br /> Site Suffix: O 1 4D Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: ��� J p�,ct��f1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 11. V Inspected By Inspector <br /> 12.0 v\SSeS- d c o 1 ►1c.�S _ 1 <br /> Physical Address l Q <br /> 1 5��� Inspection Date 5 / / 3 <br /> (� <br /> cx c A Time In Time Out <br /> Business Rep �7 Title U O AM 't O AM <br /> Co f e Q.ati S SGr ® PM J Z ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ") ® Active Q Passenger ® Generator B Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 0 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 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 /> Q Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX) N <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 /> Uj <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 <br /> Q Q Other:§ <br /> Comments \_J�AL—4)1 <br /> n ok,,I <br /> No 1110\amv�,s (�( tA(e (A.S QT� Cz)nC� <br /> Inspection Form Included: Q ' � ��r�C �� <br /> Comments Included: it 1 <br /> Business Rep's Signature Phone Number Ins tor's SignatureA76 Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X I A 1M L , 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C p L �� <br />