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Waste Tire S.. vee L3 �nsp c- ion Report. Inspection Report Number <br /> CalRecycle State of California 1 11242401 <br /> CalRecycle 181(Rev.y(Ca[ `,p Ar i®®y Form � Page <br /> Dept of Resources Recycling and Recovery(CalRecycle) �✓'M� Y�i ��11 a C�.l�J�i . <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n � a � � _ � Inspection Type(Fill one) <br /> � � a <br /> Site Suffix: L ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C C„ / If Referral,choose referral type(Fill one) <br /> Identifier: �kct,' ®VY1Yz�( Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �) t R E>n vwvy-t We-VLZ:4- t r <br /> Physical Address <br /> -755--) <br /> � �i,53aL1 Inspection Date / 2 <br /> � <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> c � ✓ Z d 0 BPM .� j ® PM <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 /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Ae_s izo ,l <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations � <br /> Q 1 Q 1Other: <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usines ep's Signature Phone Number I 4tor'_-yXg4nuZre <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � vi <br /> E A L 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />