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Inspection Report Number <br /> Waste Tire S jey & Inspection Repor ■ <br /> CalRecycle State of California 11 - 1178033 <br /> Caycling le 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 3 41 -7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �w- 1 If Referral,choose referral type(Fill one) <br /> Identifier: "'avJ c- tv�yv � wV1. j Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namey (!( Inspected By Inspector <br /> Physical Address ( i— 4mknf_ I� <br /> �`���-�•- � , �c"�v�'rL moi'� Fel <br /> Inspection Date / C' / p <br /> Time In Time Out <br /> Business Rep Title , <br /> �AM 0 AM <br /> �_ �-g� f / : 3 dO PM OPM <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 /> (6 Active Q Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 ® Otheri�e�y� <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 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 M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 /> 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 1&In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> C u <br /> &f ( j N <br /> Inspection FormIncluded: Q <br /> Comments lncluded: �� 9•Z. ':��-Y63'�T6 <br /> Business Rep's Signature Phone Number I ctor's gn ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: NZ2�) gI E X I A E L=W213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink ® ■ <br />