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Waste Tirefte & Inspection Re Inspection Report Number <br /> CalRecycle State of California Y — • <br /> Y CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 I 1 11176392 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `,� r Inspection Type(Fill one) <br /> Site Suffix: l -1 +� ' ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `\ (,_ If Referral,choose referral type(Fill one) <br /> Identifier: Q n J o r��u t o `"�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> UJI <br /> Physical Ad&ess <br /> Inspection Date <br /> Time In Time Out <br /> Business RepTitle 0 AM f ` 0 AM <br /> 00 PM 0 PM <br /> '•"'"I I �' V(3 II 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 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / FF / M <br /> 0 ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ z <br /> Commentsl�, 1 , 1 kG i N <br /> Lk)" 1_—f`[ ok-C.( <br /> Inspection Form Included: 0 / <br /> Comments Included: Au® � '� <br /> usine Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON�Aa Correct:` Incorrect: E X A P L 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cy: © 0 <br />