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2 Waste Tire S ley & Inspection Repor Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1176692 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle( <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I _ Inspection Type(Fill one) <br /> Site Suffix: i 0 <br /> 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C� If Referral,choose referral type(Fill one) <br /> Identifier: v1 tic � �ju 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> BusinessorFacility Name U Inspected By Inspector <br /> Physical Address 3 5 - <br /> t 200 � . L.L,�'r� ��(. - <br /> Inspection Date <br /> 6a-c4 CA 4 s 63 2 <br /> Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> d 1 s PM O L y 0 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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed <br /> GPS Latitude 0 Altered 0 Hauler 0 Indoor <br /> O 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 0 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 /> ' A HAULING AND MANIFEST REQUIREMENTS j <br /> — - --- — - <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 0 / m <br /> N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> N <br /> r <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 /> f <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 <br /> 0 0 Other:§ <br /> Comments <br /> - �uw�-►m,� i h � s c�v� `�y,-�� G�t: GU,.G� `els <br /> Inspection Form Included: 0 x (tag %tG S-06 2 3 <br /> Comments Included: ®-- - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCoirrect:e Incorrect >( ( E Xj A (LI 1 12 13 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y: <br />