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Waste Tire S._- vey & Inspection Report Inspection Report Nurnber <br /> CalRecycle State of California T 1 —1176445 1 1 7 6 ®I 4 5 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 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- � � � Inspection Type(Fill one) <br /> Site Suffix.: 6 5 6 15 © 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Save ` <br /> Identifier: Jccxk IAV C�tXI Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l) ` Inspected By Inspector <br /> Physical A e v'--sQQa� `v� `�i q,�� V l - Q /� r <br /> /-f Uo ✓n(Ov <br /> Inspection Date � / 1 U � � I <br /> a� 6--c CA �33� l l <br /> Time In Time Out <br /> Business Rep Title / AM / AM <br /> A0 ! <br /> i O QPM O `j 0 PM <br /> �e�us os� �, ------ <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) <br /> ® Active ® Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> Q Q - Q Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q 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 <br /> M / m / m <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) <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> sce, f� -- - <br /> Inspection Form Included: Q <br /> Comments included: �r 'C L <br /> Business Rep's Signature Phone Number Inspe is n ture Phone Number <br /> INSTRUCTIONS ON BACK [001'rect'0 Incorrect: E X A 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: ■ <br />