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Waste Tire Sum vey & Inspection Repor ,, Inspection Report Number <br /> Cal Recycle State of California 11 - 1242344 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SuryBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 n b O _ O Inspection Type(Fill one) <br /> Site Suffix: l D 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t �+ If Referral,choose referral type(Fill one) <br /> Identifier: Gn J300Ll jA()f) C0 4- t 0 CHP 0 CalRecycle0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> (�()1'ao nn�, - � C� � ES <br /> Physical Address GZyT7-0 <br /> ln,5s, o S- arl un <br /> -_f,, ? Inspection Date ? <br /> V�S O� 9S J3./�� Time In Time Out/ J <br /> Business Rep Title I 0 AM ^ O AM <br /> lJ 0 PM V PM <br /> O(Kv�cl F 1 A—i 4N �crrY,;nu1 mIA;nv.ftyv. <br /> Operational Status Tire Type Business Role Storage Type <br /> (� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) �/ 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <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 /> 0 0 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 E?(7) <br /> a <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 /> 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 <br /> in Compliance-No Violations o <br /> 0 0 1 Other:§ <br /> n 1 '1A� ,n,^, f ] <br /> Comments 1G 7/c: n ' ULa1'2 OL7.e_ Gt / <br /> �n 42 f7O�r'�lrJ�=�,; r <br /> No 11116lt�"1 JI.n5 c3V- 6kfcACk4 <br /> Inspection Form Included: 0 , <br /> Comments Included: <br /> • � 2d9zv��v3�s2c�al�tce�31'78 <br /> Business Rep's Signature ctor's Si <br /> Phone Number Ins gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M Cai)*f EXAM L E 2 3 62081 <br /> White Copy:CaIR cycle Yellow Copy:Operator Pink Copy. <br />