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Waste Tire Aey & inspection Repor ., Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245050 <br /> CalRecycle 181(Rev. (Cal 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- ' i'! G Inspection Type(Fill one) <br /> Site Suffix. `y O 2 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (Y� , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C t _ i% YsZ Got <br /> Physical Address ,, <br /> too L Uj , c tomald--Y "I - - <br /> lzi Inspection Date <br /> Time In Time Out <br /> Business Rep Title0 AM Q AM <br /> VLL(.Q_rCj6 : �C{1A go PM G O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) G� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / 0 Active O Passenger O Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other �..( Ik,� -{-Z�Q� -5e,vic 3.. <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXE 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance- No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X q EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />