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Waste Tire S,_ rey & Inspection Repot Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1176622 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surma - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `i O O © Inspection Type(Fill one) <br /> Site Suffix: (9 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: wvA J eca J'r P"i Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Il- <br /> e <br /> Business or Facility Name <br /> Inspected By Inspector <br /> HcLY4-, r,. 9rw eK Cn, LL—c— <br /> Physical Address - O <br /> ct <br /> Inspection Date Cn / S 1 <br /> Time In Time Out <br /> Business Rep Title S 0 AM ` 0 AM <br /> i [�(Q 0 PM ` 0 PM <br /> 1Y1 f S AVL ChSG 0.ri(� ' "I r 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 /> � 5 <br /> Is Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Cad$ Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 /> - -- - - 1 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 EXT) <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 <br /> 01 0 1Other:§ - - _— - <br /> Comments kivt.e. 4-1-,c <br /> Inspection Form Included: O <br /> Comments Included: 40 <br /> Business ep's Signature Phone Number nspector's Signature Phone Number <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect ;� JJJEXAM 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />