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0 Waste Tire Sul, iey & Inspection Report rispection Report Number ■ <br /> CalRecycle State of California I 1 - 1177728 <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- Inspection�( _ ' Inspection Type(Fill one) <br /> Site Suffix: t 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J p�G ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> RCt-soon 1ruc"% n:� 9 - 1 © 1 MA 'rTO <br /> Physical Address <br /> Inspection Date S / l � / I <br /> SCt� SLS Z S <br /> Time In Time Out � <br /> Business Rep Title O AM O AM <br /> ' © O Is PM � � � ® PM <br /> Q Q�sco� Owhe� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger A Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ` Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 18 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 O Referred/CalRecycle Enforcement Z <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 VC3Q- Y`2 lti►�-� �f< <1rLS{J eC�e�✓� �Ov\e n Y� � Q <br /> Ac%, k4,,,e�-�1�o <br /> v Z,v,, a.S Co�ce r <br /> Inspection Form Included: Q <br /> Comments Included: B iness ep' ignature Phone Number Inspector's Signature '{Phone Number <br /> INSTRUCTIONS ON B K Correct:0 Incorrect: 0 EXAMPLE 2 3 62081 <br /> qlf <br /> 1 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />