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Waste Tire Sull Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1178022 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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- y � � � � / � - © I Inspection Type(Fill one) <br /> Site Suffix: ` 1Q, ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier. Sam QGt t�(,1+1 Lam ) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> P a Lc� l <br /> Physical Address - C-5 <br /> , q(9b <br /> Inspection Date <br /> 7�tt v n Time In Time Out <br /> Business Rep Title B AM o ® AM <br /> Q)�n2T 0 Q PM ' V `� Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J9 Active Q Passenger 1@1 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 40 Indoor <br /> D Q Inactive • Truck <br /> Longitude - Q Planned • OTR Q End-Use 0 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 Q Car Dealer Q Collection Q Crumb Rubber j <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Cpn�f�'c, mU(71d�(A(,}lcfef' <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 Q Referred/CalRecycle Enforcement <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> 1 --- — <br /> I�� ity��Gl�'C rJns or We ILL r3�' C.c `NWn- <br /> Inspection Form Included: A,�\ vv:� '^ <br /> Comments Included: ig's &r�"; <br /> Business Rep's Si to Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: XZ E X A M P L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co Kyy <br /> ® ■ <br />