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Waste Fore Su. .ay Si: nspectlon Report ?spection Report Number <br /> CalRecycle State of California <br /> CalRecycle le 181(Rev. y(CalRecycle) <br /> 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 /> - Inspection Type(Fill one) <br /> C•' <br /> Site Suffix: `"� G� � 1 Gj f ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .yt 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> W' 16LLr Flt's C �' . G t r <br /> Physical Address I AW.44&ct s oee41` <br /> 1 3 -?-`�- 1 s . Ian sco i{- (pct . <br /> Inspection Date ,:1 •7 / (01 / 1 I <br /> c �33� V <br /> G-Wl FC C�"ti- C`"� / Time In Time Out <br /> �AM AM <br /> Title � <br /> Business Rep U ` <br /> o PM ® PM <br /> Df rc i< - <br /> Operational Status Tire Type Business Role Storage Type <br /> 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE} O� <br /> Active ® Passenger ® Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive l� Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 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 Agriculture 0 Shredder 0 Other 1U , C"-e <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS - 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 pate m / mco <br /> / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> r <br /> - 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 /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — --- <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ z <br /> Comments <br /> 001A �� �-{ <br /> .'(&.a.0 1C�i'�►'�' 4'EA i S acdz n.Ind <br /> }� flA ,YLG, L4 C'-C Vlok <br /> InspectionForm Included: 0 x <br /> Comments Included: One Number <br /> Business Rep's Signature Phone Number nspectoOu� <br /> 62031 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E X A MWhite Copy:CalRecycle Yellow Copy:Operator Pink Co ® " <br />