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02 Waste Tire Ste & Inspection Re oAnspection Report Number <br /> CalRecycle y p _ p - 1242458 <br /> State of California I 1 <br /> CalRecycle 181(Rev.y(Gai 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 / _ O Inspection Type(Fill one) <br /> Site Suffix: f V 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J vd,A Lll (0Ak 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ''11 Inspected By Inspector <br /> Physical Address CSGOTC) <br /> 33S C. V,).J�nura_ Su,�eS ' I <br /> Inspection Date $ / 0 (_ <br /> Time In Time Out <br /> Business Rep Title 0 AM 9 AM <br /> O PM 1 � L4 6. 0 PM <br /> A� 1�en�lf►a es��� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> ® Active 0 Passenger *Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) '14 <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other FvAAA Seem e-4- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ L, L (- <br /> Comments &4,r� (✓Vtn, yy,C_ Tl ac. tn��ll9^ &tea. � rt (�u le gi-nA 'T _'j'0l O�,+j, N <br /> y J�5��"`01 kA(A <br /> Inspection Form Included: "J49 <br /> Comments Included: �J� G Q <br /> fines R6pjg Sight(tur Pho a um er Insp tol Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />