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Waste Tire Sr,.. .rey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210458 <br /> CalRecycle 181(Rev.y(Cal[Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery Recycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C m O Inspection Type(Fill one) <br /> Site Suffix: I 05 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�jfj f� J Q-/,t/A �I n (01A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 11 <br /> Inspected By Inspector <br /> _ <br /> Physical Address C U <br /> Inspection Date <br /> Time In Time Out 1l 111 <br /> Business Rep Title O AM O AM <br /> 3 ' V 0 PM 3 v ® 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 Pas er 0 Generator 0 Outdoor <br /> O ® Closed 0 Altere 'l <br /> GPS Latitude 0 Hauler j� 0 IndooY/ <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <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 0 Other PJ �'�j�, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> i �Notice Of Violation � Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 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:§ <br /> Comments 5 `n5 ' 1 <br /> _j 0 <br /> L o J)0 d W J U r G _ <br /> VISA <br /> 0 0 ( <br /> mJ No_ <br /> --V tOTM AChj1'f1A ' UO3e_ TP±0' <br /> Inspection Form Included: 041nsctor's <br /> Comments Included: 0 v 2()4 <br /> Business Rep's Signature Phone Number Signature Phone Number <br /> __�7INSTRUCTIONS ON BACK Correct:40 Incorrect: EXAMPLE 1 2 3 62081 <br /> ® <br /> Copy L <br /> White Copy:CalRecycle Yellow Copy:Operator Pink ® ■ <br />