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Waste Tire Survey & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of California 11 - 1244920 <br /> CalRecycle 181(Rev. (Ca[ 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- Q' 3 l - Q Inspection Type(Fill one) <br /> Site Suffix: I O 1 ` ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: so'1 Yo �l�j w� JJ.-) CoL(� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> b �„ <br /> BusinessorFacility Name Inspected By Inspector <br /> Physical A Iln� � � � � 1 � � � ES WT-T(, <br /> C Inspection Date � / � r-7 � l <br /> Time In C� Time Out <br /> Business Rep Title 1 AM d AM <br /> 5 l C� Q PM 1 O PM <br /> `JSun U.V, <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 /> ® Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive is 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 Q 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 C1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other TrI ,9ULl& J7'-• J'W) <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 N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 Q Other:§ <br /> Comments <br /> o��o n s - <br /> G <br /> 1� n �1A�G��L1nS �S CA <br /> Inspection Form ncluded: Q 009 5V� / LR) <br /> H"— <br /> Comments Incuded: ® Busine Rep's Signature Phone &1nspeM4jtr's <br /> Signature one Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EIXIAI 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copwi:LE <br />