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Waste Tire Su. oey & Inspection Report Inspection Report Number ■ <br /> calRecycle State of California I 1 - 121018 6 <br /> CalRecycle 181(Rev.y(Ca[ 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 n / � � _ � i Inspection Type(Fill one) *- <br /> Site Suffix: _1 "� b 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Ident'rfier: � oa � C v VN ( — Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> j (� Inspected By Inspector <br /> e-5S� (` � '�G` v <br /> Physical Address <br /> Inspection Date <br /> �S2oS <br /> Time In Time Out <br /> Business Rep Tittle, O AM O AM <br /> ����0�► CJS ���� f "`�.f.�a,���. � )1 O 0 PM ✓ L � e PM <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 Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned Q 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 /> n e <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other C v C�C Dc;v: S Cvl QO <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 <br /> 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 / [T� / 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 Q1 Other:§ <br /> Comments 12_rj 0VivC k' P-5 ke- T%Come_ `&Zb 60 ov, _ N <br /> A CI e- Civ.L'� "C1n e_ «O�-l� , �,CAI.S VXO <br /> s ces A <br /> Inspection Form Included: <br /> Comments Included: � <br /> Business Rep's Signatui P�tone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />