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Waste Tire Sae & Inspection Inspection Report Number <br /> CalRecycle Y spect on Repo 0 <br /> y State of California 11 - 1177803 <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 3 -Z © Inspection Type(Fill one) <br /> Site Suffix: 1 Q Routine Q Re-inspection 4D Referral Q Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: SCkO 0 u C�tA},� C(��/�r1� Q CHP ®CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> ,C—s� e05o LoI s�I 3 q - E� 0 <br /> Physical Address l <br /> aUZ 0 b <br /> ��u Sh��� CA (n in Inspection Date <br /> Time In Time Out J <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> /„� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r�_J <br /> Q Active Q Papn ee1r Q Generator <br /> Q Outdoor <br /> O Closed Q Altered <br /> " "I"ti N, <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q 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 Q Other N/A <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 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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 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 1 cvs Q44 <br /> n",r l C�J� la L311 ,1, <br /> (No s,e- f�)�5 Pin <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Ins4 4011"tot's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I• Incorrect: E X A M P L E' 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />