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Waste Tire S%e & Inspection Re o^nspection Report Number <br /> CalRecycle State of California Y - 1244954 ■ <br /> CalRecycle 181(Rev.y(Ca)l Survey Form - Page 1 I1 12 4 4 9 5 4 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 y� (� O Inspection Type(Fill one) <br /> Site Suffix: ` v V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localee , '1 If Referral,choose referral type(Fill one) <br /> Identifier: J 14A 16 fA t f) 1 Cbu'' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> eo 04�lkl S_1 , i �1A,101I I 3 _ za <br /> Physical Address �, <br /> (AVA IN, w wvcA CAUX tA. J <br /> Inspection Date D-, <br /> Time In Time Out <br /> Business Re Title AM *AM <br /> P <br /> SC,�T•1' �,�G.Vi � eC.� tyi(���k' '3 � 0 PM � � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) h (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V S Active 0 Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 ® Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other L zlICt_�1) <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 <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 <br /> Q #. 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 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 �1f.` <br /> O liW t'A ndW <br /> Corn f)t3 VZ)Jp, <br /> Inspection Form Included: Q � 2` 4po <br /> Comments Included: eBusiness Rep's Signature Phone Number Insr's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: EXAMPLE 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />