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4 <br /> Waste Tire Sul► Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1177801 <br /> CalRecycle 181(Rev. (Cal Survey Fora - 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- ,A ' _ Inspection Type(Fill one) <br /> Site Suffix: Q Routine Q Re-inspection ® Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Sao J 0MIAl n (M"t <br /> Q CHP I& CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 1 Inspected By Inspector <br /> b&S rc\v)pg ��U( VL-1 n 1J� J <br /> Physical Add[ s J D CS Lp � <br /> W, � (vo� Ury Y76A - <br /> Inspection Date / / 1 <br /> 1 U t✓vJ C }� � � ` <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Q PM Q 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 /> Q Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive * 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 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 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> z <br /> Commentsp D Sjj1jC' 7Z 1 "WA <br /> � LL 1 <br /> 1 5 n j�pTit�C OMAA+ qM sii sSyV w, — <br /> 8�01vX <br /> �- <br /> Inspection Form Included: Q + <br /> � J <br /> Comments Included: Q -.. <br /> _ Business Rep's Signature Phone Number Insp tor's S�ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: X EXAM 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C TV <br /> ® 0 <br />