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Waste Tire SL., vey & Inspection Report. Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1229967 <br /> CalRecycle 181(Rev. (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- � � � r i ' a q - � � Inspection Type(Fill one) <br /> Site Suffix: S Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: 15(-n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ,�!!// Inspected By Inspector <br /> �9 0 ,o,�.a\ C�„Y•�'�-fie C%3 \y'� 3 `li - 1 d 1 NA A-T 7Q <br /> Physical A dress <br /> �j � C —!52 I,5 Inspection Date jVVl Z -Z 1 S <br /> e (_�' "� Time In Time Out <br /> Business Rep Title O AM f O AM <br /> RA-VC., <br /> 1 0 PM ` 0 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 /> 0 Active 0 Passenger 40 Generator 0 Outdoorg <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container3 <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 0 Other GN^ccx_-� V,P_V a`_t k:1 VIA <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-Registratidn/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 N <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �� <br /> A.o1n C <br /> 0LAa'C\z_- <br /> eA <br /> ck- .Of t' O C_Y'\ <br /> Inspection Form Included: Q I - <br /> v� 3 7 <br /> Comments Included: _ <br /> Busines ignature Phone umber Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7X*V1� EjXjAjMjPjLjEj1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />