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02 Waste Tire Suirvey & Inspection Repori. - Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242501 <br /> CalRecycle 181(Rev. (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� _ b � Inspection Type(Fill one) <br /> Site Suffix: [ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC I } If Referral,choose referral type(Fill one) <br /> Identifier: �JA(1 J QfJ��Lt�)� cu'AC 1'n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> , Inspected By Inspector <br /> 0 ov)( s `ct Ckl` � - l <br /> Physical Address l Gs co <br /> 15 33 S- S4 0 0/� 0, - <br /> L��` Q S-IyO Inspection Date C( / 2 (D <br /> 1 Time In I Time Out <br /> Business Rep Title n 0 ®AM �AM <br /> Ck� �� ��S O �� I l/ lJ 0 PM 1 0 0 PM <br /> W Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' V 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger I§ Generator a Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Tvw�1uLAL + s 4 i;e— <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 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <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 <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 /> O Q Other:§ 1 <br /> Comments 05.n ' � 5 I y !n [� Q 7f I V1AA0 t7 <br /> KSJ"tiR_ �n�GGfL, �P�U� ,�t, uil � Ni7 e; � ,� <br /> �l o V; k Un—& 0 J L, s un s 1A U rV, Cn <br /> PD 5 <br /> Inspection Form Included: 0 �S � , <br /> Comments Included: <br /> usines ep's igna ure one Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct. Incorrect: EXAM P E 1213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cok.LE <br />