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Waste Tire &ey & Ins ection Re orL Inspection Report Number <br /> CalRec clep p - 1242524 <br /> y State of CaliforniaCarrfor(R I 1 <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- O 3 1 _ d I Inspection Type(Fill one) <br /> Site Suffix: 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local / J If Referral,choose referral type(Fill one) <br /> Identifier: 5&r0 r � �� (�1 y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 161 Inspected By Inspector <br /> J,c-s 5Av-j'kb ,, '1,\ Lbs; 9 <br /> Physical Address 3 - l 0 ( C-5 60-f <br /> S L . Lo �li AV <br /> k' C A <br /> Inspection Date j / 0 <br /> �5��0 <br /> Time In Time Out <br /> Business Rep 1- J Title ` O AM O AM <br /> 3C'f L� �ll KJ A ssi S�_ � f� I J � � PM C) � PM <br /> o� � <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 /> (a Active • Passenger 0 Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR S End-Use ® Container <br /> Business Type(Fill all that apply) <br /> IS New Tire Dealer Q 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 /> 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 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 EXE <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 /> f <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 Q Other:§ <br /> Comments Q --}-ll S �{ 7' <br /> � l <br /> Q 1 G ` 1 <br /> Inspection Form Included: Q k�Q_S T7 9 <br /> Comments Included: 9 s ` b <br /> Rusin Rep's Signa Ore- Phone Number Insp or's Signature hone Number <br /> INSTRUCTIONS ON B CK [Correct.0 Incorrect: E X A M L E 11 213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop I'L © ■ <br />