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Waste Tire S( Inspection Report Number <br /> iey & Inspection Repor' <br /> CalRecycle State of California I 1 - 1177535 <br /> CalRecycle 181(Rev. (CalRecycle) <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- 6 C Inspection Type(Fill one) <br /> Site Suffix: k O -3, -7 9 - / 0 1 S Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: V\ 1 �a9 V; � i Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> sial bot-v1 Cie v c o f e �V C -3 <br /> Physical Address <br /> i2t o S. GI•,Q��1�ee LvI <br /> Inspection Date 3 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> C U l' )t' �lo.'n 2� 2 3 5 0 PM � � S 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (' C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L� J *Active 0 Passenger 0 Generator 9 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 0 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycleLo <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 <br /> N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 c <br /> Q Q Other:§ <br /> Comments <br /> 0. <br /> Co�cecV� <br /> Inspection Form Included: Q ewa^�7- � <br /> ®f 0yc" <br /> 2�1-46 <br /> B s $-328`1 <br /> Comments Included: - <br /> iness p's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ® � IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />