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Waste Tire St,. Bey & Inspection Repori Inspection Report Number <br /> CalRecycle State of California 11 - 1230275 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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 Type(Fill one) <br /> Site Suffix: , 2 � 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: J p a_�v�h �v�-�+� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` , Inspected By Inspector <br /> T's f <br /> Physical Address <br /> 6N 3 � �. C�.erol�e,e. "�,�• <br /> S� c�c C521 S Inspection Date O 2 / 2 <br /> -o �o,n <br /> Time In Time Out <br /> Business Rep Title I o, AM �►AM <br /> C/' Q PM Q PM <br /> 'V113 !"liC0.v oWY��.{ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l� 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> �PS Latitude 41 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use V 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 /> 0 Notice Of Violation Q 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 / 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 EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> N <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 In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments `. WG-S{� 'og0 <br /> a�a. 'enc �`pl..�•`�C ►���-5 �(1.o�cc�-\. <br /> Inspection Form Included. 0 1 <br /> S vL ��[ n ref- -2yQ,g/-7_ <br /> Comments Included: !" �/! l, � // er d -- - - - - <br /> Business Rep's Signattture Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: I EjXjAjM� PjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />