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Waste Tire Arvey & Inspection Repor ., Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242549 <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 /> Business Profile Inspection Details <br /> TPID- O LA - (D IInspection Type(Fill one) <br /> Site Suffix: I* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: Son � O(,(,,4 I'^ (CMA�l � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address GC WT-ro <br /> 1100 MIC kA Ca n I s c31vJ. <br /> V7 Inspection Date / I 2 / 5 <br /> f� n Ccs c� �Sa3� I` <br /> Time In Time Out <br /> Business Rep }. Title /� O AM 2 O AM <br /> � : 3 v S PM -7 � O e PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1'7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( 9 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use IV Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 4D 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 <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 <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 4 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 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 = <br /> In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments ^ s N <br /> -�Ow <br /> N� V 101U1'F4bn& o1 UJ"s can t_cin- <br /> Inspection Form Included: <br /> Comments Included: <br /> Bu ess Re_p% re Ph ne Number Insp or's Signature hone Nu tier <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: �� E X A P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />