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Waste Tire S ey & Inspection Report Inspection Report Number ■ <br /> Cdecycle State of California 11 - 1210560 <br /> ry <br /> CalRecycle 181(Rev. (Ca(CalRSurvey Form - Page <br /> Dept.of Resources Recycling and Recoveecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 4j 6 1 ( 01 ID Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� If Referral,choose referral type(Fill one) <br /> Identifier: � ��� cG Nvx,KI Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Name Inspected By Inspector <br /> (� �{717'c �'►'►YYIGti✓C �.�.I CdV>rt�L��Gi1d 5 <br /> Physical A_ ress - Z o I ///`\Prrl L1_/t <br /> A1C? zn rn .� !'�l,,.vl u'✓ A <br /> 64 113s 7? - <br /> Inspection Date / <br /> ,3 1 1 -3 <br /> "lam Time In Time Out <br /> Business Rep Title ® AM 0 AM <br /> _ --� l L ' 3 0 O PM I S 0 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 /> .� Q Active Q Passpn er I® Generator Q Outdoor <br /> /11A <br /> ® Closed Q Altered <br /> �P� Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government (a 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 /> LU <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments.n rUa <br /> �Y1>�atSY�(��7 �,-rrS of �uLtn keV(] p �i�^.h '(vlrT Sw.rc u 4-:1 11 z13 <br /> -7P-to ;f i d`E b i 41 <br /> Inspection Form Included: O <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number sp S" nature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ?VNJ EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />