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Waste Tire Sup Bey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242086 <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- ` 2 ,e,� _7 ` + - O 1 Inspection Type(Fill one) <br /> Site Suffix: ! 1 "� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n n V�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `tel Inspected By Inspector <br /> Physical Address �� - <br /> Inspection Date � 09 / 1 S / 1 <br /> TcacY CA, 95377 <br /> Time In Time Out <br /> Business Rep Title *AMSAM <br /> �OC V O J O PM S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1.\ (9 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �1 -0 Active 0 Passenger a Generator • Outdoor g <br /> 0 Closed 0 Altered 1, <br /> GPS Latitude 0 Hauler 46 Indoor �1 <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 <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 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) 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 u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 Other:§ <br /> Comments ����e \ 10. \1 DVS CLk <br /> v— v c.ecvt S <br /> Inspection Form Included: 0 ` <br /> Comments Included: v� �37 ,0Z <br /> C �� <br /> u ' ess Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK FCorrect-.6 Incorrect: X � NJ EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />