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Waste Tire SL. 4ey & Inspection ReporaInspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255781 <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- inspection <br /> (y Inspection Type(Fill one) <br /> Site Suffix: U J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( 3—ca''l1�UI n �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i c�. -- lU -P v 1 I Ar-k 0i srra in/o,-�5 <br /> Physical Address <br /> Inspection Date <br /> J 1 VC -0 <br /> Time In Time Out <br /> Business Rep Title 0 AMAM <br /> • L } ® PM 3 � G ® PM <br /> -Ton �-�r-vu.� �f-t�Y� �itv I'1�t,;�.vt <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ^'7 i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator 6 Outdoor <br /> 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — 0 Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader • 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 Q 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 Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 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 m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 10 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ��VIA.. .�;C��—t�.ca-- '�Vt_d./I'1, ..�'•_ � �iK.C. Oh`t'G�O "/� GZ/2� �, <br /> qkL"k>1(0L4"b&A u.)q-6 <br /> cyll <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Busin ep's Si one Number Inspector's Si re Phone Number <br /> INSTRUCTIONS BACK Correct:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFI\ © ■ <br />