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ek <br /> Waste Tir l-)ujq`fey & InspecUon ep�� Inspection Report Number <br /> CalRecycle State of California �q �JII 11 - 12 5 5 7 0 9 <br /> CalRecycle181R (Rev. y(Cal Survey Form — Page u <br /> Dept.of Resources Recycling and Recovery(CalRecycle) 0'J � V�i ��ss Illi BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- inspection_ Q ' Inspection Type(Fill one) <br /> Site Suffix: L 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �-, If Referral,choose referral type(Fill one) <br /> Identifier: ��I-) `-""`'L ul e�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _� Inspected By Inspector <br /> Physical Address I S Aful-XIM L. <br /> l o'44 nla dYL)5'," (loaf - - <br /> C Inspection Date <br /> L <br /> Time In Time Out <br /> Business Rep Title ',` j3 0 AM i ' *AM <br /> v Q PM I Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 331 I • Active 0 Passenger •Generator 0 Outdoor <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - End Use 0 Container <br /> 0 Planned 0 OTR <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 cv-'c,4_�j <br /> 0. <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities . W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ - <br /> Comments 'c t ��, �G, -�- da--& <br /> vt J r <br /> 4 <br /> D� <br /> Inspection Form Included: 0 2 it,_�_�� <br /> 4� <br /> Comments Included: <br /> Bu ass Rep's Si ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTI N BACK Correct:0 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />