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Waste Tire SL- rey & Inspection Repor. Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255832 <br /> CalRecycle 181(Rev. (Ca] Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q Inspection Type(Fill one) <br /> Site Suffix: I $ C� I 1 O I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `N If Referral,choose referral type(Fill one) <br /> Identifier: fJ O - O CHP O CalRecycle Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> �\ E r ,1co J�a�C��c�1s mac. 3 _ 1 O 1�/� ^�- Tv <br /> Physical Address (� <br /> IA VA 2 ��`Co yc 7A.Vo / <br /> �A IS 21 s Inspection Date 0 <br /> c��f� 1 Time In Time Out <br /> Business Rep 1 Title *AM ® AM <br /> O O PM � 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 /> i Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - 0 Planned 0 OTR O End-Use Q Container <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 fk Other vai�rb n,� _1_ �O <br /> _late-Ir <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 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O 0 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 /> a <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ <br /> Comments � •tee l,.�r�S`Gt;�`p � " -'`e-C�l9 01nP �'1n ,S �Q <br /> Mn ��TQkA�_t ONN, t' Afc-S ct� C reset' <br /> Inspection Form Included: Q <br /> Comments Included: & - - — -- <br /> Business Rep's Signature Phone Number lr specto 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:f, Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />