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Waste Tire ✓ey & Inspection Reporolnspection Report Number <br /> State of California <br /> CalRecycle T � y 7 6`� ry /� <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 11 - _'1176734 <br /> 1 1{ `R4 "!Tt <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i � I /) Q Inspection Type(Fill one) <br /> Site Suffix: I l <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 111"� C Daft 'r' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ��aJJJ <br /> c _ f Inspected By Inspector <br /> �,i n ���.►'�i'� �� oe�'., r) )I <br /> Physical Address 3 I Q I VJ <br /> q `0(70 M cae l Mvol. W lll/lll C/ <br /> Inspection Date <br /> Cuw)p Efl q Sz31 <br /> Time In Time Out <br /> Business Rep Title �+ 0 AM O AM <br /> r\LA e� `'Q 1�,t"nl�n 0 `) 0 PM Ir PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 p (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J o Active 0 Passenger 0 Generator 0 Outdoor <br /> - - o- j <br /> GPS Latitude Q Closed Q Altered Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 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 EXE N <br /> r <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 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 In Compliance-No Violations o <br /> 10 Q Other:§ -.. -- <br /> Comments n,+ 1 •. -U l 1!Q_ 1) f U!1 I <br /> �U —��� ���, 1M� ,�k� ��,� lV 11oLy,r� N <br /> No UtoWllvns (r r`" k concis. <br /> Inspection Form Included: 0 <br /> Comments Included: 17`�y J 2C� <br /> Business Rep'sSign a Phone Number _ InspeAprs Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ( � E X A M JPJLJEJ 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />