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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1244934 <br /> CalRecycle 181(Rev. (Cal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (� W(0 (W 0 U r Inspection Type(Fill one) <br /> Site Suffix: 1 p I 1 1 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SAn�,O l JLtlr cb Ulrl6 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cw,40o A7C, 3 - 1 0 J ESWTTO <br /> Physical Address <br /> sam e. uooJwjA Ave- , <br /> CA a s33� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO 0 AM 0 AM <br /> O PM S U 0 PM <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 /> Q Active..- Q Pamenngyyer Q Generator Q Outdoor <br /> ® Closed Q Altered) N /}� <br /> GPS Latitude cH�ler Q Ind I ' <br /> 0 Q Inactive Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other 6mOIA _ )elok <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 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 EXTJ 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 /> Lu <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 O In Compliance-No Violations o <br /> Q Q Other:§ ], '1 <br /> Comments .1ni 1�+ 11J k. t �On �'�- J� �1 -0V� 1 <br /> nb�erl�to, No "VA00A b) CA VA-C C.on(,sr-n- <br /> �lo.®�� i I's (An Oe,, f;e�cA PSD W ttl� n�;neA�O A U U\L-- l; <br /> G - NoLro.s JVOA O N sih._ ClbSrrT���. <br /> Inspection Form Included: Q (>✓ 1 M-31'7$ <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Insp c or's Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �Correct:e Incrrect: u EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br /> .J <br />