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Waste Tire Sup Jey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196451 <br /> CalRecycle 181(Rev. (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- cl ` , ` _ C) � Inspection Type(Fill one) <br /> Site <br /> Site Suffix: "` ' Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �ry V�� V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 3Ci - 1 0 <br /> Physical Address M pj'-�Q <br /> Inspection Date , O / 2 3 1 I 3 <br /> Time In Time Out <br /> Business Rep Title 1 O AMc O AM <br /> � <br /> ! PM , ' q d 46 PM <br /> � <br /> 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 /> e Active Q Passenger O Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateM / m / 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 EXTJ N <br /> a <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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments S ;r �� 2 <br /> CK <br /> rs <br /> SS- _ OY�CQCY� -- <br /> Inspection Form Included: Q /,/�' (� d - c •- u <br /> Comments Included: 0muse%esignature Phone Number <br /> Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JE�XIAIM� PILIE1 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />