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Waste Tire Survey On Mspection Repb� Inspection Report Number <br /> CalRecycle State cycle 181(Rev. <br /> a D �1l I 1 - 1245170 <br /> CalRec cle 181(Reay(Ca[ Survey Form 0 Page !1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) � Y�i `�+J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- G7 � .� _ D I Inspection Type(Fill one) <br /> � <br /> Site Suffix: (J / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local C• /1 If Referral,choose referral type(Fill one) <br /> Identifier: ,f I �` l Glu Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> fAd re <br /> d�ss fa Yleo 's <br /> hys�a <br /> —7 J Inspection Date <br /> Time In ( Time Out <br /> Business Rep Title 0 AM 0 AM <br /> � Y � O PM —3 � V * PM <br /> Malta <br /> 30 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W of /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V • Active 0 Passenger I* Generator * Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q 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 • 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 Notice Of Violation O Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / m / rfl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q iO 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> ,L') LJ — <br /> Inspection Form Included: O - <br /> Comments Included: <br /> Business ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: zX ve IIEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />