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0 Waste Tir *eY p& Inspection Relpro Inspection Report Number <br /> CalRecycle State of California I 1 1255726 <br /> CalRecycle 181 cover (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- Inspection Type(Fill one) <br /> Site Suffix: I lLJ �% • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(� �G Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> --,Svc_., 7_1 <br /> Physical Address <br /> 3C <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> ` ® PM Z_ 48 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Pass nger Q Generator Q Outdoor <br /> Latitude 40 Closed Q Alter d <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 _ f <br /> Q Service Station Q Hauler Q Agriculture Q Shredder A 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 /> 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 Ex7) 64 <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 /> Comments �� � � <br /> k_-C.L,�l, —h Y,-,Q . I k_ ('�Q t�:��l 1 dc'4 u- CVL cQ.stc Q N <br /> `ty-2 W�k r\ tom,• CLIQ p clP rk`• )Ike U tbLckklis tit'g O r au co � C'nACQ_-r n . <br /> 5 ]� �cto5< c.1. ►'�O �Sf Y �raw l c n c X1 5 (�cc c`n o-�� <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business g hone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: In"t: EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />