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Waste Tire Alley & InspecVan Repon Inspection Report Number <br /> CalRecycle State of California I 1 - 1242391 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> p A r ey Form _ gage 1 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) h}J� C! �J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection o � ® Q � O � Inspection Type(Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection O Referral O Observation <br /> Local If Referral,choose <br /> _ V\ / referral type(Fill one) <br /> Identifier: CHP Complaint <br /> Educational Visit Other <br /> Business or Facility Name y Inspected By Inspector <br /> C <br /> Physical Addres <br /> 1331 S- \ACk-WN Lh <br /> qs Z Inspection Date O 3 / O <br /> Time In Time Out <br /> Business Rep Title � � 2 '5 <br /> � 0 AM � � ,y O PM <br /> C� t Q PM 1Y �J <br /> Operational Status Tin: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 0 Passenger 0 Generator 0 Outdoor3, <br /> Q Closed Q Altered <br /> ('aPs Latitude Q Hauler Vlndoor%16 <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 0 End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O 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 /> �Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> _ a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> *, e��,i�O•s5y:d�a��OY��,r.aS �oee^ COC Cecc?� , �?� 1�e�5. 6C L <br /> 5 <br /> i <br /> Inspection Form Included: 0 <br /> p <br /> Comments Included: 0_4�4t u� 3�3—�Q�Q ^� �4 <br /> Bus ess Re 's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X *� VjjEjXjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />