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Waste Tire SWey & Inspection Repo. Inspection Report Number <br /> Cal Recycle State of California 11 - 1255859 <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- 1 f 1 7 - Q 1I Inspection Type(Fill one) <br /> Site Suffix: 00 1 ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Skh �� l n ca <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> '\ Inspected By Inspector <br /> T 2-2 -S VVOC�� O� 11�-S <br /> Physical Address � mA T 1- Q ) v <br /> l' <br /> o Inspection Date 06 / ` 2 / <br /> Time In Time Out <br /> Business Rep Title •AM O AM <br /> O 220. ��rC� �WV\'C I J v Q PM t C� I lJ O PM <br /> d --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)l (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passen er Q Generator Q Outdoor <br /> O 18 Closed Q AlteredX NIA- N l/� <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 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 ® Hauler Q Agriculture Q Shredder Other V, <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 Notice Of Violation Q Extension <br /> Q Q 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 EX7) A <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 /> f <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 = <br /> Q Q Other:§ <br /> r , <br /> Comments r'.�lZa� LwS �� �� O1r� a�S 6 � �a\1 P �, 0.svi <br /> llvv.. ; c t <br /> c <br /> 1921269. <br /> _V-P.Cowv,\meln�_Tem Q 7 —o\ 6e dc54- <br /> Inspection Form Included:AOB <br /> 20�^`,/ �, / <br /> Comments Included: — Y JAS <br /> s ep' P one Number Inspe or's Signature Phone Number <br /> INSTRUCTIONSK Correct:* Incorrect: M EXAMPLE 1 2 3 62081 <br /> hite Cop . le Yellow Copy:Operator Pink Copy:LEP, <br />