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Oa Waste Tire SAey & Inspection Reporpinspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245021 <br /> CalRecycle 181(Rev. (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: l� I IS Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: �� V;^ l/�, v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l <br /> Inspection Date Q <br /> Lak�nc CA S3 <br /> _1Time In Time Out <br /> Business Rep Title AM ( 0 AM <br /> PM ja PM <br /> CAS o wvtl <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger 0 Generator • Outdoor <br /> Q Closed Q Altered <br /> Latitude <br /> GPS O <br /> Q Hauler Q Indoor <br /> O Q Inactive O 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 I* 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 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 <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 E)CT) <br /> 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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> .In Compliance-No Violations o <br /> Q Q Otheer:r:§ <br /> Commentse�4 r <br /> � <br /> YT t►J 0.S Yin -r <br /> 6nyV\V1_P lAk V&SWC <br /> Inspection Form Included: Q �2 V / ^ 9z -3 v <br /> to <br /> -q;&3a N <br /> Comments Included. <br /> Business Rep's Signature Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK [C­Orrect: Incorrect: ZX 1W (� ��E�XJAJMJPJLJEJ 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />