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Inspection Report Number <br /> � Waste Tire S( ey & Inspection Repor. � <br /> State of California <br /> CalRecycle '11 - 1177554 <br /> CalRecycle 181(Rev.y(C Survey Form - 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- � � � � n � � - � � Inspection Type(Fill one) <br /> Site Suffix: b 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� ✓6 q u�y\ C©l31 y% (� Q CHP Q CalRecycle Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> i Ct�c'r� Cin e_VA:Ca- 1 -3l ` 0.�`1 k.\Physical Address 0 M <br /> \e>V C> �' A N,;.sN'r'a\ 'fit'. <br /> Inspection Date <br /> Skoc��ovl CS Zc� <br /> Time In Time Out <br /> Business Rep Title O AM ` O AM <br /> I ' -2 (-) QPM l is PM <br /> �.0'V1 h y CT a'm m b Cl G�tne('o�� f (`r <br /> r Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4D Active Q Passenger 0 Generator Q Outdoor <br /> Latitude C O Closed Q Altered A) ' <br /> GPS Q Hauler Q Indoor <br /> C Q Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> Business Type(Fill all that apply) V.--XA-t s <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 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle .4 <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Qther:§ <br /> Comments <br /> Dov �i�� waS�-e �ir2 IwSPcc�.br vie �YN <br /> h 2 `�sz_��:rk! k1,.s C,S \A.4nA-,eCK <br /> c� <br /> SQQ � <br /> Inspection Form Included: Q <br /> Comments Included: <br /> _ Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:40 Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />