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Wase gore Survey & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of California 11 - 1255918 <br /> CalRecycle 181(Rev.y(Cal Survey <br /> Form ® Page <br /> Dept of Resources Recycling and Recovery(CalRecycle) `'A bSl l3 l7 �}/ Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ 11 Inspection Type(Fill one) <br /> Site Suffix: � 1-1 U `� - S U 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: SCLV� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `T Inspected By Inspector <br /> 1-{U✓Y-a #e-au �5 �DI g-C- ' w <br /> Physical Address <br /> � <br /> Inspection Date <br /> Time In Time Out/ <br /> Business Rep Title ) AM G ®AM <br /> ` QPM S QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l 0 Active Q Passenger 0 Generator Q Outdoor <br /> o Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive I&Truck <br /> Longitude — Q Planned OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Is 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 EXT) 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 /> W <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 O In Compliance- No Violations o <br /> Q 1 Q Other:§ <br /> Comments i_u __LLQ, \ .u� C `t" <br /> A_)o )itoiabzms OY auecry 0knLes_,et, <br /> Inspection Form Included: Qfid ` <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signa ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: IEIXIAIMIPILIEI 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © . <br />