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Waste Tire f vey & Inspection Repo. Inspection Report Number <br /> State of California <br /> Cal Recycle 1 1 - 1176563 <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 2 �+ _ ( Inspection Type(Fill one) <br /> S 'i <br /> Site Suffix: 3 ® Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^-i t�_�; u y.� Q CHP Q CalRecycle Q Complaint O Educational Visit O Other <br /> Business or Facility Name �_ v <br /> cI Inspected By Inspector <br /> �-v��Ce.�.w �J c�i S S o r <br /> Physical Address 0 <br /> 0� <br /> 3 t3 �uc tc G' r- <br /> Inspection Date ' / 0 3 / f <br /> LA SszISI <br /> Time In Time Out <br /> Business Rep Title Q AM u Q AM <br /> Al Q 0 ® PM � rZ ` � QPM <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 /> ' ® Active O Passenger ® Generator ® Outdoor <br /> O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 O Inactive O Truck <br /> Longitude - O Planned ® OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture O Shredder ® Other L, -,rv,u_ s"c, f Y, <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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FTI <br /> / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> r <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O �In Compliance-No Violations � o <br /> Other:§ <br /> Comments '. <br /> 4U,S d U_t!_ a1/NGA +C'4_ <br /> ��44-� ►.�okQ,( <br /> Inspection Form Included: Q <br /> Comments Included: — <br /> C � Yb$—o z3 <br /> Business Rep's ature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L E 1112 3 62081 <br /> _ — <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C 6&�E� <br />