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Waste Tire S.,.. vey & Inspection Repoi . Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1226265 <br /> CalRecycle 181(Rev. (Ca[ 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- V/ Inspection Type(Fill one) <br /> Site Suffix: o tj{ 7 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Ct yt .,U{CtL I\1\ ZCVVItz� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C.l.vISC� ✓1 Z <br /> Physical Addr ss <br /> Q,-io CeyL+yz,. 1 Av-e,. - <br /> Inspection Date t Z <br /> -F'�'LZ"L1 CA 47-1-3,71' Time In l Time Out ` t <br /> Business Rep Title �) _ ®AM Q AM <br /> v O PM ' r v Q PM <br /> — --- — 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 /> Q Active Q Passenger Generator Q Outdoor <br /> AlA <br /> - _ <br /> GPS Latitude O 0 Closed Q Altered Q Hauler Q Indoor All A <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 /> 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 Q Hauler Q Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / Ffl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 o <br /> Q 1 Q 1 Other:§ <br /> z <br /> 4 <br /> Comments <br /> rz�llfliZ Tin ,ice t � rlLv.Ds LAU-T- e Airs t,(c k./, 5 �' <br /> .114r3 Svy rr ,s rh Q�1r�a�yt 1G �y Tl�,�'1.. rL`� ��P �'rrrS bil <br /> �,,z ,,,�,�, r✓ � ,�y( e o,,e- yid <br /> •, M c e - <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number In pec i a Wre Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IV] E X A M P L' E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ■ <br />