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Waste Tire SL. Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1177644 <br /> CalRecycle 181(Rev. y(Cal Survey Form _ Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V ® ��i -,� <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l ' <br /> S 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � " �� e,��/ If Referral,choose referral type(Fill one) <br /> Identifier: '.](;t,V\ � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy1� Address/ l v ti z <br /> J Inspection Date <br /> Time In V ( Time Out <br /> Business Rep Title O AM Q AM <br /> J� ®PM ( S � �PM <br /> L4Ave l aal(G( tarK(► 4 4rc unk,— <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Q Active Q Passen er Generator Q Outdoor <br /> O ® Closed Q Alte/ AVIA <br /> GPS Latitude <br /> O Q Inactive Q Truck Q Hauler Q Indoor <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 ® Other pL-E- rcrT'_N� dcmu <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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) <br /> r <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 <br /> in Compliance-No Violations <br /> Q Q Other:§ <br /> a <br /> Comments / <br /> ►� c,jb�,--3 -_J_P-M , l477Sb`tn C? c,, b4�l�Zc..I� �l 10', mC <br /> G Y►�Pi� �(S iP.z� � L4 `� be GLD CJ <br /> Inspection Form Included: - !l 3_T?00 <br /> Comments Include .Lij_ <br /> Aqrr� N <br /> B ness Rep's Signature Phone Number n e is ign ure Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: k�q 1E 41 _ I(' E I I 112 131 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />