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® Waste Tire S ley & Inspection Reporr Inspection Report Number M <br /> State of California <br /> CalRecycle I 1 - 1226548 <br /> CalRecycle 181(Rev. (Cil) 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- ; 3 O L $ 2 i _ , Inspection Type(Fill one) <br /> Site Suffix: (� ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y.t —1rct y. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business <br /> Jo//r Facility Name UU Inspected By Inspector <br /> /4. <br /> Physical Address 1 D <br /> Inspection Date ` c <br /> Si v c�w-� CA 9szo L <br /> Time In Time Out <br /> Business Rep Title / ® AM 0 AM <br /> ( 3 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude ------- --- 0 Hauler -O-Indoor <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 <br /> >lX�' �C�GLGIi ori - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m o <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments / 4 <br /> ad,6 rY1Cr�G�TGv� � G/,r,>o/ ,_TFn/��✓�ra�► N <br /> Inspection Form Included: 0 <br /> Comments Included: ® C�� YG $ 3 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �/ -'111213 <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 41\ X A M L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop A <br />