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%Waste Tire .'- ley & Inspection RepoInspection Report Number ■ <br /> CalRecycle State of California 11 - 1176577 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 3 3 Z 5- -2- C © ( '® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sri -`p�� � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility NameJ Inspected By Inspector <br /> SC)46'_'-tw1 Wood �k'uv I Vvi:) c <br /> Physical Address .35 - 1 O <br /> �^ Inspection Date <br /> I-" 2s-tE>L• �.vri-� Ltd 4 S z 3 / l..e <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Q <br /> c V ® PM 0 T © ® PM <br /> L Y"��K'-vvr - <br /> -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 17 S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' O ® Active ® Passenger ® Generator ® Outdoor <br /> G PS Latitude 0 Closed Q Altered <br /> 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 ® 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 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 <br /> (Required for NOV or EXT) N <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 <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 /> Comments <br /> Inspection Form Included: Q X <br /> Comments Included: ® <br /> Business R4sSt one Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � E X A M P E I 1 1 12131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :LEA <br />