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Waste Tire Sul, Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 ® 1242120 <br /> CalRecycle 181(Rev. (cal Survey Foran - 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- ii Q Inspt.on Type(Fill one) <br /> Site Suffix: I I no tine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� r„� O CHP * CalRecycle o Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `-� <br /> Inspected By Inspector <br /> `Ad-s `'1 sS - I c: 1 �n A�`T v <br /> Physical Address <br /> 26C7vk�co� <br /> Inspection Date O 6 l <br /> 1VIa��2c� C• �533� l� <br /> Time In Time Out <br /> Business Rep Title ® AM l /x� a AM <br /> MCk (� QPM r � v � QPM <br /> \Ce'� ��' 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 40 Closed 0 Altered Aj ,v f k <br /> GPS Latitude �/ 0 Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 40 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 <br /> Ca�'eewde ccc�, C,�oseo �hS �� b �.�5 <br /> w` \,•��S v� N <br /> ),)G w ca�� cry <br /> - <br /> VA �` _ `� ?9 S 36S-off v� 4 6 Cl bn A ' <br /> Inspection Form Included: 0 dei-37 l� "Zill .-1/&.32 1 1 <br /> Comments Included: 0 J / yr c b <br /> ffinessRep's Signature Phone Number Inspector's Signature Phone Number <br /> � <br /> INSTRUCTIONS O • <br /> ACK Correct: Incorrect: � IEIXIAIMIPILIEI 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />