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r <br /> inspection Report Number <br /> Waste Tire Sup Bey & Inspection Repon <br /> State of California <br /> CalRecycle 11 - 1196441 <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 Type(Fill one) <br /> Site Suffix: I 1 D —7 0 Routine ® Re-inspection 0 Referral 0 Observation <br /> Local c - -- If Referral,choose referral type(Fill one) <br /> Identifier. �� �� Vl�v� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> A U1''l N>°��c,`I�,� <br /> Physical Address <br /> VV /� Inspection Date G a "7 / <� <br /> ACC,.Vv � cA g5gao Time In ( Time Out! <br /> Business Rep Title ? 0 AM 22 0 AM <br /> J ' D 0 PM J S O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �l � � <br /> 0 Active ® Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> �PS Latitude ®Hauler ® Indoor <br /> 0 0 Inactive O Truck <br /> Longitude - 0 Planned 0 OTR ® End-Use ® 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 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 /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O 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 EXE <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> O 0 Other:§ - <br /> Comments <br /> Lo Le r A S o to 19.- <br /> w L)1,_- <br /> 9.-wb1,_- � Ltc./� Lb�cs!r-> cp I_ ,s u��L kw co�tr�tL�fz� av,�> _-s I 'n'kk'b <br /> KEG SVG ✓l t`�L6iS +1�✓ vdC CJ '�Ur� k>_ QYtJ V I C� <br /> Inspection Form�nc <br /> ncluded: I ?(_y`S� <br /> Comments luded: S _'4k� � <br /> usiness Rep's Signature Phone Number sect is ignature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: 7x*:qj E X I L 1 21 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® ■ <br />