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Waste Tire 916ey & Inspection Repor nspection Report N'Imber <br /> Cal Recycle State of California I 1 - 1176688 <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- / Inspection Type(Fill one) <br /> Site Suffix: r y `� 0 © © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -�'`�1 (-e � O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cFCk ( F)ep n r sr Lne_s <br /> Physical Address cf ` (' l f_2509 X77.$- <br /> Inspection Date o <br /> Time In Time Out <br /> Business Rep Title ®AM AM <br /> _ � _r� t °Z O PM 3 r Q PM <br /> IZWI - i PI'V►1 IYt¢c)[ Y 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 /> ' 0 ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed 0 Altered <br /> GPS Latitude Q .Hauler -Q-aa.door-- - <br /> O O Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) NIA <br /> Q New Tire Dealer Q Auto Repair ® 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 4 <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> L O Other:§ <br /> Comments < <br /> M C101XA rte. Y�4 i r dzZA, C k'd 44ca mct vi <br /> Inspection Form Included: Q <br /> Comments Included: ® Z�f� Yb�''.04 3 <br /> Butes�.lep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect X E X I A I M I P41 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />