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Waste Tire ."S fey & Inspection Repoi 1Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 117 7 5 7 3 <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- // �!7 [ Inspection Type(Fill one) <br /> Site Suffix: 1 d Z IL / - 0 1 4& Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50.r% TOol V\r` CC)V yx 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name \' Inspected By Inspector <br /> C�tcag2 �n e.�t�o e Co v'"�c'r i G <br /> Physical Address 3 -! C� 0,A- Q, <br /> Inspection Date / �7 <br /> S�oC��ovt 52�Z 2 L L. <br /> Time In Time Out <br /> BusinessRep I��1 -- 1 Title 1,. �J l 10 AM l n O 0 AM <br /> Pe_6tt tL ! " LTi h ?Ck 'CS* C� O PM h • PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active • Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 • Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 - 0 Notice Of Violation 0 Extension <br /> § <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 /> 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 /> 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 /> 2 <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:§ 1 <br /> Comments V- ` <br /> o <br /> OV \ � � W0.ST'C lore 1�5 4P eC' wl AmV, C-*)V1 <br /> TtV) <br /> CCD,-,CCS c h <br /> Inspection Form Included: 0 _ 6 <br /> Comments Included: —� zL��J %� ���� <br /> Business 9 <br /> Rep's i nature Phone Number Ins ector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � ® g EXAM P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />