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Waste Tire ve & Inspection Reput 4 In.pection Report Number <br /> CalRecycle y p _ p - 1-17684. 3 <br /> State of California ` m I <br /> CalRecycle 181(Rev.y(Ca[ 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- r C t-7 I ) / _ Inspection Type(Fill one) <br /> Site Suffix: I J 1 "1 (p 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: S u� VO u)n C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ��.5 la AO 3 q _ � � � Ben ESA <br /> Address <br /> Inspection Dale 2 / O a- / I I <br /> I <br /> L a AzA)c L A 9S23-1 <br /> Time In "f"iiZ7e Out <br /> Business Rep (� I TitleJ O O AM O AM <br /> HUlMQ QJ G1 1 l ® PM ®-PM <br /> (�U�� <br /> - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) J_ 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �J ® Active 0 Passenger ® Generator 40 Outdoor <br /> O 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 /> 0 New Tire Dealer • Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> • Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ® 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> co <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 <br /> 0 <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> I � A6-�s z <br /> Comments Q- ) s�-�I s 17%R QC� Jonk- <br /> Inspection Form Included: Q <br /> Comments Included: vuis — <br /> Business Rep's Signature Phone Number Inspect 's Signature one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A P 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C py:L ® ■ <br />