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Waste Tirip�rve & Inspection Re ®rt Inspection Report Number <br /> CalRecycle y p <br /> y State of California 11 - 1255717 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page I <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �. r„ /„ /( '� Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. i 1 V ✓1 Coo- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> 00s-f-( o roe <br /> Physical Address n / IU <br /> 2-t' W tut ►'Zp(CQ.S �CQ rcc�ts /LOQ�- <br /> Inspection Date , r / / 1 57 <br /> D �S`Z4v <br /> Time In Time Out <br /> Business Rep Title C/ ) 4 //_ •AM *AM <br /> fL1 � PM � � � S � PM <br /> �Gz r1�S 72X' ) ll a S use <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1(J 0 Active * Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler � Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O 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 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 /> Q Q, PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FTI / 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) N <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 /> LU <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 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ __ <br /> Comments <br /> ( LU • <br /> cw <br /> Inspection Form Included: Q <br /> Comments Included: g <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCorrect-0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />