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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 12422-7 <br /> CalRecycle 181(Rev.10/1 <br /> Dep0) ecycSurvey Form - Page 1 <br /> t.of Resources Recycling and Recovery(CalRle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 L " _ O ' Inspection Type(Fill one) <br /> Site Suffix: Routine O Re-inspection O Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.1f\ �� �� co O CHP O CalRecycle 0 Complaint O Educational Visit 0 Other <br /> Business or Facility Name t Inspected By Inspector <br /> 50. Mocv ^L>v.c, 3 <br /> Physical Address <br /> vs <br /> Inspection Date O Z / O 7l.u �o+� �C gS330 <br /> Time In Time Out <br /> Business Rep Title c 0 AM 0 AM <br /> I ' 5 / 19 PM &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 /> (/® <br /> 0 Active * Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered N IIA- <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive . Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 • 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orEXTJ N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ \` <br /> Comments W Off\ �hCo2 �y�SA -'�y`n �Y`2 E`N1 :�t 'Rwn <br /> O{ JtS��aS C&- (Or Ce-C`n <br /> Inspection Form Included: 0 <br /> Comments Included: ` 9.3j AG <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � q �JEJXJAJMP L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />