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-0-Waste Tyre S&6y—InSpectTon R-elyort4ilnspection Report Number <br /> CalRecycle State of California I 1 - 1196528 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page I <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: 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ()� ao&Cr V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> !Fce&e,.\a,5 v�Sic - Q ,�`7 TQ <br /> Physical Address <br /> Inspection Date <br /> CXTime In Time Out <br /> Business Rep Title O AM U O AM <br /> t n^_ � ' © d ® PM ` 0 6 PM <br /> C"la�Gv� "� U.�+ J ��� 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 /> ' !Active Q Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude I Q Hauler ` Indoor <br /> O Q Inactive Truck I <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) cask- <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader p Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Othervcsec <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 Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / Ffl <br /> / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest 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 /> ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments T�)M-� .O - V.ZG-S'cC. ��� ®Y�CiP��'C�b`n &.CW\2— C>Y\ <br /> Kin ®�o\a, -0 WS (tC ce-cl_S o� clnhce�v\. <br /> Inspection Form Included: Q r <br /> Comments Included: <br /> Busines�Re'slsignat Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � V E X A M�',L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />