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Waste Tire St., Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1177783 <br /> CalRecycle181(Rev. (CalRecycle) Survey <br /> 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 () 0j O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local f� )_ If Referral,choose referral type(Fill one) <br /> Identifier: �Cvt� war VPC/� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr ss 25 9 1 o l t46At76U LA <br /> Inspection Date S / l <br /> CA q / Time In l Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 1 0 P ' -0PM <br /> :mss pa\ Ga✓��no.. C,�.m� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' (� ® Active ® Passenger a Generator Q Outdoor <br /> -" o <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR ® End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m m N <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 E)(T) 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> 6r:;mrvl&v& <br /> Inspection Form Included: O <br /> Comments Included: ® <br /> ine Rep's Signature Phone Numbers c r' S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : ® ■ <br />