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Waste Tire S ley & Inspection Repor Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1176677 <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 Type(Fill one) <br /> Site Suffix: 3 a S C7 3 b O C ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S��n 7w� Q CHP Q CalRecycle Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> (_� G K <br /> Physical Address 3 0 <br /> �3�(ZTt to <br /> Inspection Date <br /> Time In Time Out <br /> Business <br /> Rep^, Title ® Q O ® AM � ® AM <br /> QPM � � � Q PM- <br /> -- - -- - perational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / 0 Active Q Passenger ® Generator Q Outdoor <br /> -- -- 0 <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q 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 j ENFORCEMENT STATUS <br /> --- <br /> �V A HAULING AND MANIFEST REQUIREMENTS <br /> --- — -- --- - - - - --- 1 O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 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 Cl) <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> 10 1 0 Other:§ <br /> Comments /� <br /> /1C1Y 7 1' e, //7(�!?,� i`C/4N� jiC aGLw IICJV✓irim+ - . <br /> Inspection Form Included: Qt6l�4 v <br /> Comments Included: ® - — �'///i CZO 7 �fb� C <br /> Busine s ep's Signa re Phone Number Inspector's Signature Phone Number <br /> ,� <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ( v E X A L E 62081 <br /> 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink opy_ <br />