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I <br />Waste Tire Sup rey & Inspection Report nspection Report Number ■ <br />cal6ecycle State of California a_ , 1196510 <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 - � 1 Inspection Type (Fill one) <br />Site Suffix: �j �j * Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: ��,^ �d 0- - J 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name r Inspected By Inspector <br />Physical Address <br />763 <br />Inspection Date I / I 8 / I 3 <br />` - C Time In 1 Time Out <br />Business Rep Title ��\\ � J C 4V AM *AM <br />.- `v p ` 1 V 0 PM � I � O QPM <br />Operational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />D <br />0 Active ® Passenger Generator ® Outdoor <br />O 0 Closed 0 Altered <br />GPS Latitude 0 Hauler 0 Indoor <br />O 0 Inactive e Truck <br />Longitude - 0 Planned • 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 • Other �at�2ho��C2 5�p <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS <br />_ 0 Notice Of Violation Q 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 />PRC § 42956 - Registration/Decal in Vehicle <br />0 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date m / m / m <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CalRecycle N <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers 0 Referred / CalRecycle Enforcement <br />Uj <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: § <br />Comments CSA '�Y���d d?� aA& <br />rP <br />section Form Included: Qyy���i <br />Comments Included: � x � O �� �' <br />I Busin ss Rep's ignat a Phone Number <br />Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK I Correct: Incorrect: Xli� VIIEIXIAIMIPILIEI 1112 3 62081 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® ■ <br />