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Waste Tire Arvey & Inspection Repor ., - Inspection Report Number <br /> Cal Recycle State of California 11 - 1230347 <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- � � Q � � � O I Inspection Type(Fill one) <br /> Site Suffix: Q Routine ® Re-inspection Q Referral Q Observation <br /> LocalG I If Referral,choose referral type(Fill one) <br /> Identifier: 'SG1n 0U' l L4'� Util � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Businerss oar Facility Name Inspected By Inspector <br /> Wt4c UvCt t-1101 <br /> Physical Address 3 - l 6S to -To <br /> �0 ab S� <br /> Inspection Date / 0 a / ) 5 <br /> Sib�z��� CA gStio� <br /> Time In Time Out <br /> Business Rep Title AM0 AM <br /> �j ' `� <br /> f 4 C tk r� � _ I 0 T�J 0 PM � lJ J 0 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) t� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �C / ® Active Passenger I* Generator 0 Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR ® End-Use ® 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 ® Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer ® Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture ® 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) <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 •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 1 !Cv' 1 � a Iia 1i� �¢,-1')T -r✓, �.�0 U� `�"�i S �, <br /> AM nicnl ouz:l \11 a� nn3 ��(Xrfedod' <br /> Inspection Form Included: ® <br /> Comments Included: ® /" ,g �- <br /> Bu iness Rep s Sign ure Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (� EJXJAJ JEJ 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />