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Waste Tire Strve & Inspection Re or , Inspection Report Number <br /> CalRecycle y p p <br /> State of California 11 - 1230328 <br /> CalRecycle 181(Rev.y(Cal 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- ' � O � � � � � O_ � Inspection Type(Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> Local ,e ���� If Referral,choose referral type(Fill one) <br /> Identifier: ACl VCA 1 (,U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I <br /> (v(�UeclteCates 3 5 b <br /> Physical Address — ES u)TT o <br /> _WS Inspection Date / 10 S / 1 5 <br /> S�oc o CA Time In Time Out <br /> Business Rep C Title 1 <br /> Z 0 AM 1 0 AM <br /> �(�•S(n. P'D'3i'L�P� `� U 0 P f Q <br /> 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 /> ® Active ® Passenger IQ Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q 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 /> ®Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 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 M57 <br /> / D S / , S <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> E <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments PLOAN CA—\A)tn.S� i 11 <br /> See. <br /> Inspection Form Included: Q 41nstor'Vs'Signatun <br /> Comments Included: TW -- <br /> Business Rer's Signature Phone Number ePhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: <br /> 7* <br /> V EXAM P L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co V <br />