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Waste Tire S ey & Inspection Repor" Inspection Report Number ■ <br /> Cal Recycle State of California 11 - 1176680 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ Inspection Type(Fill one) <br /> Site Suffix: Q q a L ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physics Address 3 <br /> 4uo 6,.r C ce. <br /> Inspection Date / t 8 <br /> U 1 <br /> Time In Time Out <br /> Business Rep Title n 3 ®AM ! ® AM <br /> C% Q PM I / ® Q PM <br /> `- (�(iy/�- ✓Y�^�?� - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /j'� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Y QPassen Passenger <br /> 0 Active <br /> Q Generator Q Outdoor <br /> GPS Latitude ® Closed Q Altered O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q 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 IS 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 O Extension <br /> O O 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 m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 (9 In Compliance-No Violations <br /> 0 1 0 1 Other:§ - — --- <br /> Comments <br /> e ala )J`-C__L�[ <br /> ol �'Idf CL <br /> Inspection Form Included: Q / t� <br /> Comments Included: ® �. f4c tc� � 7`� "� <br /> Business Rep's Signature Phone umber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [ 62081Correct:0 Incorrect: X � EXAM 123 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy <br />