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Waste Tire Still Bey & Inspection Reporit Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1210333 <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- 1 Inspection Type(Fill one) <br /> Site Suffix: (� "� b v * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q1/1 �y�v �rJ�, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - • ` Inspected By Inspector <br /> W-\\Sor <br /> Physical Address <br /> 1S -z"s �1c�� <br /> kockAo Y-\ CA q51205 <br /> 2 O5 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> � PM � � � � PM <br /> S�oMf�h er - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / Z (Fill one only) (Fill all t_hatapply) (Fill all that apply) (Fill all that apply) <br /> ' t7 ®Active r-'4aa'sennger 0 Generator 0 Outdoor <br /> - O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned • 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 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q 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 Q - Q Notice Of Violation � Extension <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 /> Q 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) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments N <br /> Voila- � \'\Mj"'C' \ •3M-S here.&. <br /> mvn n\ak"'OW5 acr Co,nce c n <br /> Inspection Form Included: <br /> io��j`,-6 � Zai-y68-3zB <br /> Comments Included: <br /> Bus' ess Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />