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Waste Tireftey & Inspection Repo"tspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1255765 <br /> CalRecycle 181(Rev. (Ca[ 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- � / Inspection Type(Fill one) <br /> Site Suffix: `C \ <br /> Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 7 i0 Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Vv Inspected By Inspector <br /> Physical Address <br /> Inspection Date 1 f 1 5 <br /> 4 j C-VA-0 n cA- L S�oS L I r <br /> Time In Time Out <br /> Business Rep Title / ®AM 0 AM <br /> tOiAran n �7� [ C: � � QPM � I I � O 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 Q Generator Q Outdoor <br /> Ol-_ <br /> GPS Latitude O O Closed Q Altered n CL /Ll� <br /> 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 /> 0 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 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 / 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 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 u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments Lko.-'b?wdoll, Gtti —ki[i D l a7& a_x 4l( TI& C �lGlCc 6 <br /> AA <br /> Gle A- Y -�d. .• wrey r o i ,;Q • �Q� G�C 7�CJ l'Lo �-2� <br /> Sj" ��t -U!. e-+�e�,c� a, ca t roc <br /> T'T 51ftZ 4-f-C)I I <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business lip's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I• Incorrect: 7X EIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />