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Waste Tire SL fey & Inspection Repor' 'Inspection Report Number <br /> Cal Recycle State of California I 1 - 1177539 <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 , Inspection Type(Fill one) <br /> � <br /> Site Suffix: 7 6 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.Y\ J aac� %3 r Coo-v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> i fis, SLC q - o t <br /> Physical Address tt�� <br /> Inspection Date � / 05 � ` 3 <br /> �oc�`�o VA C G521 S <br /> Time In Time Out <br /> Business Rep c \ �} _ Tiitl�e, Q 1 Y10 AM 10 AM <br /> Vh C� d�E1`T 4V-I ifv !J O 1* 1 0 PM <br /> �Ss�sf4��tfi <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger • Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 40 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q 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 • OtherVL'�Cvv�p�CZ� <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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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:§ t `` <br /> Comments A:v� �`" l'��r� �h2 C9� i5 0.Y��1� ��R <br /> G.S <br /> QS COVICgzryl <br /> Inspection Form Included: Q <br /> Comments Included: Ak <br /> Busines p's Signature Phone Number Ins�Ctor's Signature _ Phone Number <br /> orrecINSTRUCTIONS ON BACKFct: Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />