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Waste Tire & ey & Inspection Repor Inspection Report Number ■ <br /> calRecycle State of California 11 - 1177548 <br /> CalRecycle 181(Rev. y(CalRecycle) Survey <br /> 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- ? l r 1 _ Inspection Type(Fill one) <br /> Site Suffix: 1 v 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC(It) <br /> If Referral,choose referral type(Fill one) <br /> Identifier: SO.yti Jd 10'"n v%rk V V 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name " I Inspected By Inspector <br /> Aw,tdd,n C%. P � - l a l 1�1,0- <br /> Physical Address <br /> 1 b kb C7 W. k..�h h,e, V_CJ` <br /> Inspection Date Z / 1 q <br /> T 117C�_LY c A- 9 s 377 <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> I � QPM ' 2— � 0 � PM <br /> Pre�..(an�a1 Sip. <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 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned • 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 OtherVS�r�a\ <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 0 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <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 0 In Compliance-No Violations o <br /> 0 0 Other: <br /> Comments Qov�ti r`Q �tc'S�2 ` —k <br /> tA-e 1v`S r C A ►n (7v � ._fir-`1"., n� <br /> 0.,v �._ kti e \1 o w:f <br /> �A vi t� i �nS Of 0.rC4S 0� C�vtCff 1n <br /> Inspection Form Included: 0� <br /> Comments Included: Zt vv <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X AjMjPjLjEj 1112 31 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />