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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1230103 <br /> CalRecycle 181(Rev.y(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- O O � O � � � � Inspection Type(Fill one) <br /> Site Suffix: l ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s(����U/,U� �� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name "I _j Inspected By Inspector <br /> CIU k1 kl l t GI� Sbl - <br /> Physical Address 1 ES L 0 TT b <br /> 2O9� N - C c e,\nAve- - <br /> �1S�1S <br /> Inspection Date u / O 171 S <br /> 1 <br /> Time In Time Out <br /> Business Rep TitleO O AM O AM <br /> ® PM 3 v 0 PM <br /> 1 ' <br /> eve. SC,�ne��M(�n S�l�-s CQ , <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 /> 0 Active 0 Pakspnger 0 Generator 0 Outdoor <br /> 0 ® Closed 0 Altere1,Q l � I /V {{�� <br /> GPS Latitude 0 HauleA 0 IndooA <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other NIA <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> rV A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ y L J <br /> Comments n\l u l INNS�cr 1'1�1 n5(JQ t �� �I4 f&L(W 1' <br /> cxc-, S11�f; k ( 1 �►� ()r S 1i�- -�-t)L!`"S �Lrs 4U�Sv�1bum <br /> fiwo�,�Q, �L''L S 101 a�luolfrAln Gil' ' Wj "Vtr ('0 <br /> Inspection Form Included: 0 <br /> Comments Included: 0-- <br /> Business Rep's Signature Phone Number Insp c or's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: NJ E X AMP L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />