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13142849195 <br /> Waste Tire Survey.& Inspection Report Inspection Report Number ■ <br /> CalRecycle state of California81( I 1 - 118 612 9 <br /> 'CalRecycle 181(Rev.y(Cal 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- In <br /> spection� t'� ]�E <br /> � - O � Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or <br /> Facility Name II Inspected By Inspector <br /> L r rl.Q/ I _ 1 / 10101 <br /> Physical Address L_�/_I <br /> I <br /> L 2;3 W54GL �V <br /> J <br /> Street J <br /> Inspection-Date O c, / 1061 <br /> &000,i �j t�3"� Time In J Time City State ZIP Code me Out7 <br /> Business Rep // Title <br /> 16 PM (! I S 0 ® PM <br /> L .,n^• �i' ILS. o _�._ __J (� . _ <br /> Operational Status Tire Type Business Role •Storage Type <br /> - ` <br /> Tire Count(Whole/PTE) D (Fill one only) (Fill all that apply) (Fill that apply) (®all that apply). <br /> I I 3 0 Active 0 Passenger Generator Outdoor <br /> 0 0 Closed 0'Altered <br /> GPS Latitude m. 0 Hauler 0 Indoor, <br /> O 0Inactive &Truck <br /> Long6de - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0.Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateM / M / m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 1.4 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f CalRecycle Enforcement <br /> E <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsif In Compliance-No Violations o <br /> 0 0 Other:§ I -� <br /> Comments { N <br /> G o lroSPO <br /> V <br /> 6 7111L ,s h.,J 141,,,-�J fd e Lw, CTL O <br /> e//t c. -1d , a ,�• Nits w) I ` ) <br /> Inspection Form Included: 0 . t� Q [Qj�� 0/�� /1y J <br /> /1/1 p,-CTr-J I t G <br /> Comments Included: 0 - <br /> B ess Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �X�VEXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ' ■ <br />