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Waste Tire Si rey & Inspection Repor' Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177533 <br /> (C <br /> CalRecycle 181(Rev.10/1 <br /> 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- 1 ' t O C O Inspection Type(Fill one) <br /> Site Suffix: 1 "1 -7 I* Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: CV� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Bussiiness or Facility Name v 1 ( Inspected By Inspector <br /> Physical Address ��b�Ve` �j G�ZGI 3 <br /> 152- 3-7 Noc kk,, <br /> Inspection Date <br /> Lo CA q5z`?- <br /> Time In Time Out <br /> Business Rep Title Z O AM 3 O AM O PM A PM <br /> joS� ��v,er•e2 Geh. JVlac� <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 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • 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 �1 v <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 <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Lo <br /> e <br /> (Required for NOV or EX7) `•° <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 In Compliance-No Violations o <br /> Q Q Other:§ , e �1- <br /> Comments Yle 1 V%.5 1P <br /> eGAi_on Aa N2 c,✓ AA <br /> \ ,%S oK0.A-Q <br /> c>��ow��� w0.S �o ked <br /> o c q rerzS c� Co-1Cc rh <br /> Inspection Form Included: Q <br /> Comments Included: . -�0Jc�� / �ON 209't1ot'3z8i— <br /> Bu ' ess Rep's, ign re Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />