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Waste Tire Sley & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177806 <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- (y O ' Inspection Type(Fill one) <br /> Site Suffix: l r �p L Q Routine Q Re-inspection 0 Referral Q Observation <br /> Localc� If Referral,choose referral type(Fill one) <br /> Identifier: J�t 0 Ctq LA' <br /> t n (b TA4 Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> {� L l Inspected By Inspector <br /> ` 10 rl�er L��ndi 1 <br /> Physical Address J q 0 C-,60 <br /> _150t S_ VIA- U <br /> VJn`n) Inspection Date 3 � / l 3 <br /> vl 1 Time In Time Out <br /> Business Rep Title i C 4 AM j ^ 0 AM <br /> 3�svI S \ l 5 J Q PM 1 c� • PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passe ar Q Ger at r Q Ou-ttd11000r <br /> O ® Closed Q Altered �j� /v( A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 Q 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 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 /> 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 /> Q Q 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 <br /> r. �� �osu�- ��a� A � w �R�,��1�7L10S�s7- U)� _ Sem <br /> ri <br /> Inspection Form Included: Q / r _A�,i L��3 1rA <br /> ^ _ <br /> Comments Included: Q `(C <br /> VNACK <br /> ss Rep's Signat a Phone Number Inspe or's Signature hone Number <br /> INSTRUCTIONS Correct: Incorrect: E X A M P LIE( 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� <br />