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Waste Tire SG. Bey & Inspection Report inspection Report Number ■ <br /> Cal Recycle State of cle 181(R I 1 - 1230366 <br /> CalRecycle181(Rev.y(Cal Survey Fora 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- I Inspection Type(Fill one) <br /> Site Suffix: 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: q U r W v✓��Y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L ` <br /> Inspected By Inspector <br /> Toe G-ohZo-\25 �r1'n'cAI\,h:k _ 1 1® � ���- V <br /> Physical Address <br /> 7 99S �Z;�h <br /> Inspection Date � � <br /> 1 vICLV\k-2C� 537 Time In Time Out <br /> Business Rep `a Title C &AM 1 � ®AM <br /> O PM 1 L 0 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I C (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 40 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 46 Indoor <br /> O Q Inactive * Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <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 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) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 1 Q 1Other:§ ` ` <br /> Comments \�nSQSE �c=v� V�-! en T���&'Ct n.4 kve <br /> - 1��o ��.I;,�.nt��t-: c.�1� ' (i C- i�1�4 S tet- 1.c�1n r p P✓� <br /> Inspection Form Included: Q t/ <br /> Comments Included: <br /> A.sine�s 's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK �Correct:le Incorrect: E X I AMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />