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Re % Inspection Report Number <br /> � Waste Tire��e & Inspection <br /> CalRec cleP -1176829 <br /> State of CaliforniaCal'rfornia <br /> Y calRecycle181(Rev.10110) Survey Form - Page 1 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- � � `7 _ O I Inspection Type(Fill one) <br /> Site Suffix: J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCt,-() J&(,�ju,1 r\ Co I O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '`` Inspected By Inspector <br /> \�vo'4. Sao A4o p;s>�11�1css <br /> Physical A ress <br /> Inspection Date 8 1 `7A'rI 1 <br /> op (,� t533� U 1 1 <br /> Time In Time Out <br /> Business Rep Title � 1 5 Q AM � � 0 AM <br /> PM O PM <br /> I <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 /> Q Active Q Passenger Q Generator O Outdoor <br /> C Closed Q Alttr Nal V)A,GPS Latitude Q Hauler', Q IndocfrF1 <br /> � Q Inactive Q Truck <br /> Longitude — Q Planned 0 OTR 0 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 V Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> o O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> LU <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ l i1 <br /> Comments z. li <br /> r'c 1f1S iyf- �� ht lk+e�6nA _0l <br /> �1csF'cs- gv5�nass ��Ag Llos V�c.c1_ �n c1„�— <br /> kk a� �u s; s ( -}�ni5 -kcis i '`Aakw � y pi5m�cn �tr5'' fl 15�3�7 <br /> Inspection Form Included: Q <br /> Comments Included: Q— -- <br /> Business Rep's Signature Phone Number Inspe is Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correctj.ejjnco�rre�ct- X �� q E X A M PI 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: A © ■ <br />