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Waste Tire Slkey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242149 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50-V-1 � Cc,011:� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 11 Inspected By Inspector <br /> Physical drd\ as 3 9 <br /> 1k165 S. �_% <br /> Inspection Date 1 O / -Z / l� <br /> ��&6 -7 Time In Time Out I <br /> Business Rep Title M O AM 2 O AM <br /> C <br /> V"COW �"�` , `�C, �C. ' ' 1 2- O PM Z (ISJ 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) -79 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active ! Passenger 10 Generator 40 Outdoor53 <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned • OTR Q End-Use 0 ContainerZ5 <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 6 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 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 i <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> a <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 i In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: �%Lus*in <br /> , <br /> Comments Included: <br /> dp Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: M � E X A M P LIE 11213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA �� <br />