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Waste Tire Sley & Inspection Repo AInspection Report Number <br /> CalRecycle State of California I 1 - 1242531 <br /> CalRecycle 181(Rev. (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- � � O O � Inspection Type(Fill one) <br /> Site Suffix: 10 Routine Q Re-inspection Q Referral Q Observation <br /> Localt r._ 1 If Referral,choose referral type(Fill one) <br /> Identifier: S uCl J UGI q��n W un-1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> l � <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 �� <br /> a� 2 g(0s'- <br /> r 11 Inspection Date <br /> l ot. 1 <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> QPM V 'S 0P <br /> ����'.C�cam. �e'C'�• <br /> Operational Status Tire Type .Business Role Storage Type <br /> Tire Count(Whole/PTE) v-'1/ Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i Active 0 Passenger A Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 4D 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 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 /> 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 Date m 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 E)C7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 Q Other:§ <br /> Comments <br /> 6A = <br /> Inspection Form Included: Q 0,9 <br /> �1 <br /> Comments Included: 4 �1 / Dv ��A 6 <br /> usines Rep's Signature Phone Number spe is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X l;� q I EXAM L 112 13 1 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink :L <br />