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Waste Tire Sley & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242071 <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 I Inspection Details <br /> TPID- e t , Z , _ C ` Inspection Type(Fill one) <br /> Site Suffix: J� ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �0-yN '3"C:, ,^ V;� �v� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �"� Inspected By Inspector <br /> - M Tei. t 1 <br /> Physical Address � 1 l V <br /> -3c>\s` 1�r.�V.w�Q ?v� <br /> (( Inspection Date © $ � O <br /> Tc" C ,y <br /> Time In Time Out <br /> Busiinesss Rep 1 Title O 5 •AM AM <br /> O PM � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) '31 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger * Generator I*Outdoor I <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor y <br /> O 0 Inactive 40 Truck Longitude - 0 End-Use Container Z <br /> 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair •Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years a <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 1 Other:§ <br /> Comments ��M _ _ A <br /> etre s. sem— c� ��n et ,�C'�s��e c, ,s a. VK <br /> dy\s c 0� C( mzes r1 <br /> Inspection Form Included: 0 1t ON <br /> Comments Included: <br /> Business&gnature Phone Number Inspe or's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � NJ E X AIMI AIMPI LJEJ 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />