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Waste TirloSoeY p& Inspection ReltriOnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255742 <br /> CalRecycle 181(Rev.y(Cal 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 /> C) <br /> Site Suffix: �i 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: j.� Tr,-� �'� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> (J{� -I-cA rL S ✓1 ?> / _ ( O 5AM 1�M-4-, k4 6t(--X 1 <br /> Physical Address <br /> Inspection Date <br /> iVlf!)-I�..tLC a'- C 41 S3 3 4— <br /> Time In Time Out <br /> Business Rep Title r ,I' Q AM Q AM <br /> � � 7 OPM � 1 .30 <br /> L OPM <br /> �'OilCR rtX� TCLVa_&-4 (Y� fa�iwr <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 Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader 0 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 0 Other Ttoor( j) s+rf b"1v- <br /> / <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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / M / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) N <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 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 w <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance-No Violations <br /> Q Q Other:§ <br /> Comments <br /> L,,t.)�IJt:2� 1�.� � 4w,•p-finn (XVYuc� N <br /> Owl K <br /> ctv 6 c_ h <br /> Inspection Form Included: C _ <br /> Comments Includ d: A,- <br /> Bus ines natGre Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE I 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />