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Waste Tire Sui Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1210506 <br /> CalRecycle 181(Rev.y(Cal 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- 1 q p - Inspection Type(Fill one) <br /> Site Suffix: t l 4b Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier. S Q n i5cl, �LA,l f\ WQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CA` 3G - t 0 1 c S z�Tib <br /> Physical Address 1 <br /> �10\0 2OaA_Aj ;4l �(). 1 _ <br /> C-406tA_0 Inspection Date <br /> J Time In Time Out <br /> Business Rep Titll�e� � -SQ O AM � � O O AM <br /> 1.tnr�� i1Ml�r�O(,� lit,wo1 f ® PM ® PM <br /> - 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 /> ® Active 0 Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive i Truck <br /> Longitude - Q Planned ® OTR Q End-Use O 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments r11 0,, &ade rM UI'Z(h rk11(A 1j 4Q41UW�'H1 <br /> 6j. urtA t s d (J>n f rn- <br /> Inspection Form Included: Q - fi l� -1 <br /> Comments Included: ® t,— N —317 <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E X A I LI&I 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : © 0 <br />