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Waste Tire Su, rey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1230168 <br /> CalRecycle 181(Rev. 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- ^ Li � Inspection Type(Fill one) <br /> � � ® � 9 <br /> Site Suffix: * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: so'n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name —� — <br /> A� Inspected By Inspector <br /> Y1 �C�6 Q. <br /> Physical Address <br /> Inspection Date ` 0 / 2- 9 `i <br /> oc1LYa S Z®3 <br /> Time In Time Out <br /> Business Rep Title *AM 0 AM <br /> O PM 0 PM <br /> �oc�e ��-J es�S�c• M � <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 0 Passenger Generator 10 Outdoor j <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 4& Indoor y <br /> O 0 Inactive � Truck <br /> Longitude — 0 Planned 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 G`�S® <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 /> 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)C7) N <br /> v <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 �in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments t 1 Yds(��C'�t�� �Y�e (3y\ i in�5 Q <br /> Q S vrl,0 \ <br /> Inspection Form Included: 0 n ^v/q�� <br /> Comments Included: <br /> ISO O- _ <br /> Business s Sig at r Phone Nurrf er nspe to Signature Phone Number <br /> 21 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: y � E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />