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Inspection Report Number <br /> � 0 Waste Tire Sup vey & Inspection Report --p � <br /> CalRecycle State of California T') - 1176356 1 1 ` 6 `� 6 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 11 / �! < <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 Type(Fill one) <br /> Site Suffix: ( 1 -� P l ® Routine Q Re- s iot Val Q Observation <br /> FTI <br /> Local <br /> If Referral,choose refealone) <br /> Identifier: S +CSV/ VC,I(�Q�t/(,� �-f t/YV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V ll Inspected By Inspector <br /> Physical Address <br /> Inspection to <br /> Time In Time Out <br /> Business Rep Title Q ® AM PM O AM <br /> ep PM <br /> Operatio al Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one o ly) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> > > <br /> ti Q Passenger ® Generator Q Outdoor <br /> O ® Closed Q Altered <br /> N/A <br /> � <br /> GPS Latitude Q Hauler Q Indoor <br /> O Ive 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 /> 8 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 EXE N <br /> 'r <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 <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:§ z <br /> Comments 4 14�c <br /> r1 t Y V�f[�1 YIJ Ala V,b k,6 <br /> L, 11, 10001 7`n�b <br /> - s Q(r +�.ss ) a ? l �l`�r Z5-7 . <br /> l)Zev -7-P --- /10-71697 uyz; n <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> • �'_C ,U dam• -y .Y � <br /> Business Rep's Signature Phone Number In ctor' ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct-0 Incorrect: E L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® ■ <br />