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Waste Tire SL v vey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1210597 <br /> CalRecycle 181(Rev. (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 Type(Fill one) <br /> Site Suffix: L L ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 6a.v­t 0Uft'_/"V\, 6ck�%",� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> Physical Add!: ss - Z I �q 2 <br /> ^'tt2 �L/T <br /> //�� Inspection Date <br /> cA <br /> Time In Time Out <br /> Business Rep Title &AM <br /> / AM <br /> nn Linn I. ` L E Q PM � � I t � O 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 /> ' •.7 ® Active ® Passenger ® Generator 0 Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler 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 /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q 0 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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: ® <br /> Business Wgnatre Phone Number I"s r g Lure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect: E X A JAKL I E 1/1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y:LEA ® ■ <br />