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Waste Tire SL_ . _jf & Inspection Repopection Report Number <br /> CalRecycle State of California( I 1 - 1178042 <br /> CalRecycle 181(Rev.y(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- Inspection Type(Fill one) <br /> Site Suffix: 5 Ll S � l � (& Routine Q Re-inspection Q Referral Q Observation <br /> Local ll If Referral,choose referral type(Fill one) <br /> Identifier: �� �.�� Gt;V✓1 r� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ii// -- Inspected By Inspector <br /> Z oe'Ke'v iWV _✓_ � C'✓) ��G -� <br /> Physical Address S ( f0 <br /> v <br /> losgc:;;' 4j 6WeA_ R� <br /> _ Inspection Date � / g ^ / <br /> Time In Time Out <br /> Business Rep Titl�e/ O AM O AM <br /> Ni�� �� Y l�vw�. ✓ C>)__ t/ G ® PM ,s 3 tJ ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1, i0 Active ® Passenger (V Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned 4 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 EXn N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 o <br /> Q Q1 Other: <br /> L�v�v►t fil'1 / z <br /> Comments <br /> U,z>Ic -( YK <br /> Inspection Form Included: O <br /> AsRep's <br /> Comments Included:0 Signatu Phone Number I ec s g ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />