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02 Waste Tire SAey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1255837 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: "� 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v;� ����/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namew rr 7 Inspected By Inspector <br /> L.ovp_' Covov�ry Skoc�S tet- <br /> Physical Address <br /> 1 S ZSo <br /> 24 Z Inspection Date �7 L me <br /> / "� 1 <br /> Time In v Time Out L <br /> Business Rep e.,qtf Title I AM p� AM <br /> I%- 6 ' `` Is 0 PM v s ® PM <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 Q Passenger 0 Generator ® Outdoor 19 <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 Container <br /> Business Type(Fill all that apply) <br /> 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 /> 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 <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 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 C2 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 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 /> z <br /> Comments <br /> —k-D VN_s� ak <br /> O�— iNmc>_!> 64 <br /> Inspection Form Included: Q •. 20 ��p0 JCa y <br /> Comments Included: l <br /> Business Rep's Signature Phone Number Inspe is Sign ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: I E I X I 4MI P E I 11 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pinkpy:LE © 0 <br />