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Waste Tire Skey & Inspection Reporm Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255808 <br /> CalRecycle 181(Rev.y(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- ' C _ G ! Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ] r,1 ,� � ��Ctrn� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �►c1 Stc�nz, AYlieYi(os 11 5CPU,rtj1j"', C. c.� <br /> Physical Add" ss ' ) - Q 1 '5)1)Uav&-, kj�if"w <br /> 2 c:�s; Inspection Date 1 Z Z <br /> Time In Time Out <br /> Business <br /> :Rep Title 6 1 ®AM J Q AM <br /> ��`� �� 1--�CYZ►rll� t � i� QPM I ` S ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O� `-�' <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed ® Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned O OTR End-Use IR Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> *Notice Of Violation Q 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateC, 1 MO ,+ <br /> ! <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 0 In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments �- /Q _e <br /> TZCit,c�t..Y�K L>!�[ls np—o f f , o` ! L[,.�L���L _G ld�Q L/Y-Lli�Gs' (.� L7� k11� <br /> n 11 6& <br /> i J- <br /> Inspection Form Included: 0 <br /> Comments Included: * <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> �,{ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X NJ EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />