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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California I 1 - 1176560 <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 /> iness Profile i Inspection Details — <br /> _ o Inspection Type(Fill one) <br /> Site Suffix: 0 9 9 3 7- 0 ! 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .y.� }L,- 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Othe: <br /> Business or Facility Name —J Inspected By Inspector <br /> �'Iv GIC IzJ-► l ycvmcc h� <br /> Physical Address f 3 - ` l rJ,tee✓.-7 LIV <br /> 3.�0 o GJzrE . <br /> Inspection Date <br /> F�C./C 17 S- Time In Time Out <br /> Business Rep Title ® AM ` � � -5— <br /> ®AM <br /> /vIa ` 6 QPM QPM 1 <br /> -- JI <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 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> rBusiness Type(Fill all that apply) <br /> C) New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> I <br /> sed 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 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 N <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 o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> 0 Other:§ -- -- <br /> Comments <br /> action Form Included: 0 <br /> �Z�4� YGx3�-Q6Z <br /> Comments Included: ® -- --- -- --- --- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbed <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect ( 1 J! EXAM L E 1 2 3 62081 <br /> - - - <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />