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Waste TiAurvey & Inspection Reolrt Inspection Report Number <br /> CalRecycle State of California I 1 - 1245200 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey _ <br /> Business Profile Inspection Details <br /> TPID- I I � (\ !'1 Inspection Type(Fill one) <br /> Site Suffix: 7 lJ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: j!L T� a R U(Y) C 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> -D, f So�� _ � 1 � / ,/r7/� <br /> Physical Address 3 7 V J S MU YR, /W <br /> _ Inspection Date l 6 3 / <br /> Time In Time Out <br /> Business Rep Title G 0A1 0 AM <br /> Ca-r-1 ll� a VL V I C-e- 0 PM -� ® PM <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 ® Passenger 0 Generator 4) Outdoor Z <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor I C u <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 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 A r/A6 !1�w Sync <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 § - 0 Notice Of Violation 0 Extension <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 EXE C2 <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 /> 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 0 Other:§ <br /> Comments--�lt�.v�'�.� 1..�� ,�,._.! _ •-1—, '_ �. 'I V'�Zk.I�Z�"1 ��lYls�.� G%Vl `—i'yGG� <br /> 1 �jC lUI�cJIX Vl,l�. c o <br /> V16 <br /> Inspection Form Included: 0 A <br /> Comments Included: ® �' <br /> Business Rep's Sig ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: � IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />