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Waste Tire Spey & Inspection Repor'GInspection Report Number ■ <br /> Cal Recycle State of California 11 - 1255868 <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 O Inspection Type(Fill one) <br /> Site Suffix: O Routine O Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � — ;� yV� O CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> hy 6��5�C�CfLv\ C>� �TGGc�p'l q I v <br /> Physical Address �J 1 <br /> Inspection Date� /"�lJ 7 Time In Timei Out <br /> Business Rep Title 1 ®AM O AM <br /> ( , S 0 Q PM Z ® 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 /> Q Active Q Passenger Q Gejr for Q Outdo r <br /> o 0 Closed Q Altel'2d` v <br /> GPS Latitude <br /> O Q Inactive Q Truck Q Hauler Q Indoor <br /> Longitude - Q Planned Q OTR O 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 & 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 /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 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 O Other:§ <br /> Comments C�x� �"*Sc <br /> �i 1, <br /> a. 'Che. k ►►\``MPr' UG \S <br /> �• �v ;res �aS 1� 0223-a1W1 ��e-C�S� . <br /> Inspection Form Included: Q <br /> Comments Included: Q 3Za <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />