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LLLJ0VJvv0J <br /> Waste Tire SI ley & Inspection Repoll <br /> Inspection Report Number <br /> Cal Recycle State of I 1 - 117 6 4 3 4 <br /> CalRecyclecle 181 181(Rev.y(CalRecycle) <br /> - <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: W-s]3 Z l 1 3 [©11_ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ..-t# Q CHP Q CalRecycle Q Complaint Q.Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 / - 1 0 <br /> Street <br /> Inspection Date <br /> city <br /> lit y U ����tate ZIP Code I Time In Time Out <br /> C <br /> Business Rep Title O AM Q AM <br /> 3 O O PM S PM <br /> _ . Operational Status Tire Type Business Role Storage Type <br /> 1 i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) . ( I <br /> L_1--j- —I 1 _1_- I_ S Active Q Passenger IN Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> o Inactive ® Truck <br /> Longitude - 1 I7_1 0 Planned Q OTR 0 End-Use Q Container <br /> L_ <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O 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 /> Notice of violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> A <br /> O O 14 CCR§18459.3-.Retention of Comprehensive Trip Logs for 3 years <br /> 0. O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O Q Other:§ L j _ <br /> - 2 <br /> Comments <br /> �1vx�, PY7t/X�t�frrcati �jiC G��f1. l}_..si� 71d�-/�1�tnrii?.Qi �, <br /> .14-4&f <br /> Inspection Form Included: Q eo <br /> Comments Included: <br /> Bus' ess Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON ACK C r t: Incorrect: X �0 9� REjXjAjMjPjLjEj 1112131s2os1 <br /> White py: cycle Yellow Copy:Operator Pink Copy:LEA <br />