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Waste Tire SL.. Bey & Inspection Rep®V-. Inspection Report Number <br /> Cal Recycle State of California 1 - 1245054 <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: ` _) 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � ®O��CS �Q V►� If Referral,choose referral type(Fill one) <br /> GlIdentifier: rOCHP OCalR�CalRecycle 0 Complaint <br /> OEducational Visit OOther <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 6Aqsn 1 Inspection Date 0 7 / O z / I S <br /> (� Time In Time Out <br /> Business Rep Title &AM g AM <br /> 1 l LJ O PM I O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 'Z (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> Active. .0 Passenger 0 Generator IS Outdoor <br /> 0 0 Closed 0 Altered <br /> GP� Latitude Q Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude .— 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ! Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance-No Violations o <br /> Q 1 0 1 Other:§ <br /> Comments ��c .�� 1t ; y <br /> Inspection Form Included: O p 2 <br /> Comments Included: ��/ <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAMPLE I I 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />