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Waste Tire S 'y & Inspection Repor Ispection Report Number <br /> CalRecycle State of California 11 - 1176642 <br /> CalRecycle 181(Rev. (CalRecycle) <br /> 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 Inspection Type(Fill one) <br /> u <br /> Site Suffix: 1 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 90,y) pct Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> >,M L � � _ � <br /> Physical Address ( /1_-�� 60r_A,�A <br /> '4 as Ll C_ • �rY conk S f . - �m <br /> Inspection Date <br /> 1�� � 1� 5S;2/S` <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> I 1 3 Q PM 0 ® 0 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 /> 140> > <br /> ® Active 0 Passenger ® Generator Q Outdoor <br /> - - o <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> o Q Inactive A Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) F <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 ® 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 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 EXT) N <br /> n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <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 S In Compliance-No Violations o <br /> Q Q Other:§ - — — -- <br /> Comments z <br /> I l s1w1 j lx--� <br /> Inspection Form Included: Q x <br /> Comments Included: <br /> �� C7O y(eZ5-db <br /> Bu ess Re ure Phone Number npec rs ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:eCt:0 Incorrect: E X A P L 1 <br /> 1213 62081 <br /> ----- <br /> White Copy:CalRecycle Yellow Copy:Operator Pink py: <br />