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Waste Tire Su. Bey & Inspection Report inspection Report Number ■ <br /> calRecycle State of California 11 - 1196268 <br /> CalRecycle 181(Rev. (cal 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- Inspection Type(Fill one) <br /> Site Suffix: l <br /> �j Routine Q Re-inspection Q Referral Q Observation <br /> Local e- If Referral,choose referral type(Fill one) <br /> Identifier: �Y1 J am_\, COW�,� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AQAress Q l J�m ,� <br /> -I--I j MYYL� zr , <br /> C� � � �',Q Inspection Date <br /> J�Dc( ►�� ��`�� Time In Time Out c <br /> Business Rep Title 0 AM 0 AM <br /> o ® PM C, ® PM <br /> V � U vie! ( a� Operational Status Tire Type Business Role Storage Type <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> f ' ® Active ® Passenger & Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 <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 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 Datem / m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle R <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 <br /> 0 <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 /> see, r <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> ep's Sign t e Phone Number _VspeltoWlSign ure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X rA I M L E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .L © ■ <br />