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Z Waste Tire Sti.vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1210561 <br /> CalRecycle 181 cover (call Survey Fnrm s Page <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey V�r NJ 9�9 11 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: $ g 6 y C l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `` /-_ -_ If Referral,choose referral type(Fill one) <br /> Identifier: CtV\_ \"+V1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> P�ySi al Ad ress YVL-C1 LZ'GcJ fl )c .. L. C1 t� 1 <br /> 343a �vul.J>v►3cr Gl—: — <br /> Inspection Date <br /> ell qSlJ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> -. ' 3 S ® PM O v JOPM <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 (a Generator 0 Outdoor <br /> -_ �i Al <br /> GPS Latitude O ®Closed 0 Altered 0 Hauler 0 Indo <br /> 0 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 /> 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 <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> LU <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 � J <br /> �iav�n,e, ��� nr.�•-►���� ,.._ �,�,. A/c, <br /> l r 21�.�y,`L� ��!L�� �v� g�YL AQ�J Vy"L k <br /> -}�, ,,,r,�rN�b �/Iv� Z�'✓O '�1V�� ttrr 'AAS - /Cwk r /M <br /> b.✓>-Kt­$-� &.4v-, iz- .S ,ah`b�at2 c rw -►1•uy IR # /a8876'F Je 'C <br /> Inspection Form Included: 0 <br /> Comments Included: © <br /> Business Rep's Signature Phone Number i7PeVt6r—*t-,gZature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: jEjX[AjMjPjLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® 0 <br />