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Waste Tire Spey & Inspection Reporenspection Report Number <br /> CalRetcyde sWeor�«1a I1 - 1226378 <br /> CalRecycle 181(Rev.y(CalRecycle) <br /> Survey Form - Page 1 <br /> Dept.or Resources Recycling and Recovery(CalRecycle) <br /> Part A_Suryey- _- BLUE OR BLACK INK PEN <br /> i <br /> Business Profile _ <br /> Inspection Details I <br /> Site -Suffix: � <br /> St Inspection Type(Fill one) <br /> Site ` � � � <br /> Q Q Routine Q Re-inspection Referral Q Observation <br /> Local t--C��V If Referral,choose referral type(Fill one) <br /> IdentifierSa,VI <br /> �'���. Q CHP Q CalRecyde 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 'Inspected By Inspector <br /> 4i1fAWddm1CsL�aC_ ampe-ZPh <br /> D rto > Avi — -- ——- -- -- - -- — ` -- - <br /> � Inspection Date j / 0 (, I <br /> rime In Time Out <br /> Business Rep Title O AM <br /> 0 AM <br /> OWeW 121a..re,- - <br /> Operational Status Tire Type Business Role Storage Type 1 <br /> Tire Count ole E) 1 ' Q (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> 18 Active Q Passenger 0 Generator 0 Outdoor <br /> GPS Latitude _ - - - —0 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> Q Inactive ® Truck j <br /> Longitude - , <br /> _ Q Planned Q OTR Q End-Use Q Container <br /> Business type(FII all that apply)_ <br /> -0-Ne-w- Tire Dealer Q Auto Repair Q Trucking Feet Q Government Q Retreader • Q Dismantler Q Tire Derived Fuel I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 40 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 /> - _, . _ -_. *Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste lire Hauler Registration and Transport of Tires <br /> PRC <br /> Q Q §42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> D : Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / �y / / z <br /> 4 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle V CJ l I� i <br /> Q Q 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ 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 p Referred/CalRecycle Enforcement <br /> I <br /> Q , Q '14 CCR§18461 -Mani#est 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 , <br /> Q Q Other.§ <br /> Q In Compliance-No Violations <br /> Comments - <br /> Inspection Form Included: ® 4#5` <br /> Comments Included: <br /> eP, g re Phone Number s Si afore Phone Number <br /> INSTRUCTIONS ON BACK I Corrie Incorrect: I '� E X A M P L E 1 2 3 62081 <br /> White C py: nec le Yellow Copy.Operator Pink Copy:LEA <br />