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Waste Tire Sdkey & Inspection RepoAnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1244908 <br /> ry <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© Inspection Type(Fill one) <br /> Site Suffix: A, � "� � ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1� If Referral,choose referral type(Fill one) <br /> Identifier: *�V�N�Nt n Nn 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ^, 1 1 1 Inspected By Inspector <br /> I.uvJ (C-n(� L tc.c(ovc, OuAitnr%1 Lcbv f4��� _ <br /> Physical Address l b , CSCo'�`s <br /> SfkL 300 ( Olrul 140110U <br /> Inspection Date 7 Z D 1 S <br /> Time In Time Out <br /> Business Rep Title 1 ®AM 1 AM <br /> Q 5 O PM � I - 6 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive • Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use S 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 0 Agriculture 0 Shredder ® Other NEA1ktitiJtl Lobb lw uJ <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 0 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 /> 0 0 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 /> 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 0 Other:§ <br /> _ d Comments <br /> Inspection Form Included: 0 , <br /> Comments Included: �� ` <br /> �ep's Signature Phone Number Ins to�1, tureone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C4*______ <br /> LE <br />