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Waste Tire Su. vey & Inspection Repork. Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1226507 <br /> CalRecycle 181(Rev. <br /> (CO) 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 Type(Fill one) <br /> Site Suffix: I�Yn I\U� y 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S>G n-To (,(1 n CN j't� 0 CHP 0 CalRecycle 0 Complaint O Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> sWO� 3 - ) a <br /> Physical Addre 1 Gs 1 i, o <br /> XW0 S�0� Ave,- W�,V <br /> C fl J c-S��� Inspection Date <br /> M <br /> �a�e Uk, `I Time In Time Out 111 <br /> Business Rep Title 11 1 O AM Q AM <br /> ' j Q LSIIJIP(1� <br /> so PM (� ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' J ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® 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 <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 m / m / m <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 EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 <br /> ®to Compliance-No Violations o <br /> 0 0 Other:§ ll_ 1 11 <br /> AA <br /> Comments Qo\,4A M t za, c 41 �e 1 I1-_5ot Won n O )S A.Y1 <br /> Cl»»� <br /> LASeus'- <br /> V; <br /> Inspection Form Included: <br /> Comments Included: <br /> `i3� g-. <br /> Business Rep's Sig ture Pone Number Inspe is Signature hone Number _ <br /> -- - -------- - 62081 <br /> INSTRUCTIONS ON BACK �orrect:* Incorrect: , VI EXAM L 1 2'L3] <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co • © 0 <br />