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Waste Tire f0ey & Inspection Rep(, . Inspection Report Number <br /> CalRecycle State of California - 1210309 ■ <br /> CalRecycle 181(Rev.y(Ca] Survey Form - Page 1 11 1210 3 0 9 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 7 Inspection Type(Fill one) <br /> Site Suffix. Z '1 CJ ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SSV, �d V�r V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 913T ((3v-t era , L c <br /> Physical Address `�� V <br /> Inspection Date 2 3 <br /> GS2bS <br /> Time In Time Out <br /> Business Rep (�,, / Title 0 AM U► 0 AM <br /> B;1t J v`�-lf�� S`no �v eCviSo� 1 I 0 PM 2 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive 40 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <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 EXE N <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 a In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments .�,ey�ti,r.2 L,.�a.S�C• ��Z ��SP�G�•t,�y� �,r,v�e. Q� �C�n,�S �� o�r�e�l. <br /> Areas 47 CQy\'.2f r1 <br /> Inspection Form Included: <br /> - ��t-Y6�328y <br /> Comments Included: <br /> Business ep's signatuY Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />