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Waste Tire 4 iey & Inspection Repos Inspection Report Number <br /> CalRecycle State of California 11 - 1177582 <br /> CalRecycle 181(Rev.y(Ca[ 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- � � � _ � t Inspection Type(Fill one) <br /> Site Suffix: \ # Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Vin 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> u Ove j- S -3 ,- d 0.t 1v1v <br /> Physical Address <br /> pp Inspection Date 2 2 1 I 3 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 ' 3 0 0 PM 2 © Q 0 PM <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 /> C (2) ® Active 0 Passenger &Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <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 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) n <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 W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f1fIn Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments i \ <br /> Pk`OJ i`n e"- W c, 1 NL->P eG bel Ac3 y,� 0 Y), <br /> G,✓��, k�2 k c�l`p Wir` W c..S VGA e� ` <br /> �0y`%.(5 t �0v.5 ac- OL MCL c!> c o�nce�V1 <br /> Inspection Form Included: 0 n � fie, -4 6�-3 2$ <br /> Comments Included: - <br /> sp c <br /> Business Rep's Sig ure Phone Number Intor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P L 1 E 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />