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`nspection Report Number Tire St_ .ey & Inspection Repork <br /> State of California <br /> CalRecycle I 1 - 1176576 <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- C, y C� � , _ Inspection Type(Fill one) <br /> Site Suffix: 3 / O / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identrfier: w�'1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr P�'CG.i C. o--TM(9_LA__VV1 x?NV <br /> UNC <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> I ' 3 Q QPM 1 S I® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 39 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger * Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® 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 40 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 IENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -� <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 (Required for NOV or EXE 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 W <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments '' <br /> KU►.yfTYtci �•c� P�;tiw '7'"�i f� G1cy3F1 ��,cly�-'°� <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busin s ep's Signature Phone Number LI spector's Signature Phone Number <br /> INSTRUCTIONS ON B [Correct- Incorrect: 6— � � � `E X� A E 1 2 3 2081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />