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Waste Tire Wey & Inspection Repo Inspection Report Number <br /> CalRecycle State oc California I 1 - 1176589 <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 Inspection Details <br /> TPID- i 4 _ t Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c - u� <br /> CJGtM y'\ *-1.�-f'�1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name IF _J <br /> Inspected By Inspector <br /> L_',U M i S C�-�Y�O Cc;, <br /> Physical Address J h C - U L3 uE 2.j J <br /> 4 3 rhl �, vi ' cy- , <br /> Inspection Date /� / 0 / <br /> CA q�;-.z o s w <br /> Time In Time Out <br /> Business Rep Title ®AM AM <br /> ff�� /� <br /> + - -- Q d 0 PM 0 O O PM <br /> Dr-c",V" r1 A ►CJt i ✓Le <br /> tn,�t <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> Ca P� Latitude Q Hauler Q Indoor <br /> 0 ® Inactive Q 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 A 11►ti3O'fz'cE ce' P­U0_* <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> ---- -- - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> —-- --- — --- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 N <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:§ i <br /> -- — - z <br /> Comments 1 <br /> I✓&) Gt S VA 01-,Cj 2 <br /> Inspection Form Included: Q <br /> Comments Included: ® ��'� � ��✓�S <br /> Business Rep'sSignature— Rhone-Number- -- Anspector-"ignature Phone-Number <br /> Incorrect <br /> 0 V, E X A M E 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct: <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />