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0 Waste Tire &,vey & Inspection Repor., Inspection Report Number <br /> CalRecycle State of cle181(R I 1 - 1226515 <br /> CalRecycle 181(Rev.y(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- ` / _ © I Inspection Type(Fill one) <br /> Site Suffix: * Routine Q Re-inspection Q Referral Q Observation <br /> Local r- ( If Referral,choose referral type(Fill one) <br /> Identifier: 5 qY) Jo a,4,n CUitin Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ti(e s `1 Le-,,,5 q _ _ <br /> Physical Address 3 I I Q (A --o <br /> -� bIA61 <br /> ,, Inspection Date <br /> Time In Time Out <br /> Business Rep Title a6 V O AM 'l /� 7� 0 AM <br /> ® PM J . V V ®PM <br /> tit\11 �aw ti,r 6`n S , <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 /> ® Active • Passenger is Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler � 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 /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date ( <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulQ Referred/CalRecycle Enforcement <br /> ,J Haulers erreaeyme <br /> f <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments I 1 1 1 <br /> w O�t,Srt, ln3 c `� i lAn �W1n <br /> Inspection Form Included: O 14- <br /> Comments Included: (5-'06' Z. <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W 62081 <br /> JJJJEXAM L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L © ■ <br />