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0 Waste Tirefte & Inspection Re Inspection Report Number <br /> calRec cle Y <br /> State of California 1242342 <br /> � <br /> Y CalRecycle 181(Rev. ®�'C4/i� o � �� 1 — 1 2 4 2 3 4 2 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey A tl a <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` rr e Inspection Type(Fill one) <br /> Site Suffix: L , 9 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: 5 C'. J p i t q ii11 f-\ f <br /> CO AQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> Physical Address q ) C��O <br /> Inspection Date <br /> �iSZbs 1 J <br /> U Time In Time Out <br /> Business Rep Title 1 , 0 AM J� AM <br /> 1•( ® J � S <br /> WA&A5 AA5� /q GWneT -PM 0 PM_ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 1 p7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> �� 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 /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exn <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <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 /> Comments V f- -41 f e- I nW2t)V1 U''% Uhl YY1S LCI e ri(� "1 <br /> Inspection Form Included: O h <br /> Comments Included: ® —3� / <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (� E X A P E 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink py: <br />