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Waste Tire S,.. vey & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of California 11 - 1242492 <br /> CalRecycle 181(Rev. (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- ' e 15 ` O Inspection Type(Fill one) <br /> Site Suffix: �Q l0 ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SrnC� Jvj�Gl�;^ C��A1l 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> \J`a1t� _ PI <br /> Physical Address 5 C� <br /> aas (CA <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 8 AM O AM <br /> h1+( V O PM ' O V PM <br /> ,l v e+r10 F2T C� b Pk�n}-� P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) pA (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered i1 v/A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® 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 W PY,in� ff_WnU+1AJ nl r <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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Lo <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators A In Compliance-No Violations o <br /> 0 0 Other:§ LL �(. L 1 <br /> Comments p mmw �a) v `;!cr 1 n6.k1,"a p U-,4l-%;f <br /> v.> LAS n *cA= 1 j f <br /> N d `� 1l)lq�l r,��Q�(A Je S 0+ Conct fn <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> �6v a �8s �loov - C <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �� E X A M L 112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />