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Waste Tire Sley & Inspection Reporpinspection Report Number <br /> State of California <br /> CalRecycle I 1 1255820 <br /> CalRecycle 181(Rev. 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- -2- <br /> Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C �r3 a C,6\ 'f\ C(�Vh Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date O 1 1 J 1 { <br /> C �,�� �. 9�2�6 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM � . � � %PM <br /> LOP Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 7 L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' V 0 Active 0 Passenger 0 Generator 0 Outdooryd <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor 36 <br /> O Q Inactive 4&Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 0 Other � ��\rv��:a-Y\ Cep,,,, <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 / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q 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 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 /> Q Q Other:§ <br /> Comments ` belne— C�-tP_ Ct e <br /> 'T VJ hC3 � <br /> �ce�:ev5 0XeJt C& (S9ree.(_r. <br /> G c as co^Cem <br /> Inspection Form Included: Q <br /> za— <br /> Comments Included: OZ401 <br /> Business Rep's Signature Phone Number Inspector's gignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � q 11 EJXJA1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />