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M Waste Tire SL, ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1177574 <br /> CalRecycle 1181(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: ` Z • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \ V`k% 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> 00 <br /> Business or Facility Name Inspected By Inspector <br /> PA V� ��c� S Tlr2 COQ 0.Y\ � O <br /> Physical Address Y I <br /> 55`AS <br /> C� 9520 1 <br /> Inspection Date 2 / 2 / ` 3 <br /> Time In Time Out <br /> Business Rep J US�`i b y 6�nso h Title 2 AM 2 ^-� � AM <br /> JoS� <br /> ✓"`dlrid�'e d 7 S O PM ' L V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(V1lhol may, O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `b 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 1 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ 1 { <br /> Comments VOV k�e — ��^'S pCe-kzCN j_ �.oh� (")V\ 'TVIk f> <br /> C' H.4 � <br /> 1 V \j zona :o.�. �} r exceciS <br /> Inspection Form Included: �, <br /> �'�l' bilo L e 1 Za°t� `l.0_Tiz 2 <br /> Comments Included: � ""��"�- —� <br /> B 1. e ep's Signature Phone Number Insp ctors Signature Phone Number <br /> v 62081 <br /> INSTRUCTIONS ON K [CorrectO Incorrect: JE�XIAIM�PILIE1 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />