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Waste Tire St Yey & Inspection Report` Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177538 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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- -7l , � � O 1 Inspection Type(Fill one) <br /> Site Suffix: ") ® Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'r1 aomi'.) V�� �V h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> CO.\: &0�n� a. J\A- )t�a\S enc. . 3 _ o l M <br /> Physical Address <br /> Inspection Date —3 / , -1 3 <br /> 5�or_\e, <br /> Time In Time Out <br /> Business Rep Title [� 0 AM 0 AM <br /> ' / •PM 0 PM <br /> �.5• 'R-o cis Caw h�'C' <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill on nly) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � � fr{�n. <br /> Active Q Passenger Q Generator Q Outdoor <br /> O OF Closed O Altercdk N« NjAr <br /> Ca P$ Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 I*In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> P C_C t.,+� t` l a S O n <br /> C>L..3—\ WaS Vt0Z"�G ll,i'� ?o a vow D� a't45_—Q �tz�ttCh <br /> 1Jc 5� ,tt�� �S4y\o ckt v�c(- o Qua. 3 ` ova pt�_L^Q >�csai :0vn_ <br /> �iah jA,0 to � k_n 37 6 �{q • <br /> Inspection Form Included: 0 <br /> �a�."' <br /> Comments Included: Rep's S <br /> 0Nr Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � �J E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />