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Waste Tire SL. rey & Inspection Repon 'Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242081 <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- + � � � � � � _ � � Inspection Type(Fill one) <br /> Site Suffix: 1 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Cy-\ TGCL4 %4'%Y\ <br /> � O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> - M`- <br /> Physical Address <br /> 27a Lb 9CA,ft p <br /> Q 2 y Inspection Date O g I , LA <br /> Q Time In Time Out <br /> Business Rep Title AM ( *AM <br /> IF <br /> �� � \Y O QPM � ` � � QPM <br /> c recta . �� � <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /y 9 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active 0 Passenger 40 Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 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 0 Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 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 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 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 <br /> o�a_k7t�Gyk5 Kor_v <br /> Inspection Form Included: Q <br /> Comments Included: )� v ` r <br /> Business Rep's Signature Phone mber Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E�XJA�MJPJLJEJ 11 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />