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Waste Tire Su. ,iey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210512 <br /> ry <br /> CalRecycle 181(Rev.y(Ca(CalRSurvey Form - Page 1 <br /> Dept,of Resources Recycling and Recoveecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` �.y a Q S _ O I Inspection Type(Fill one) <br /> Site Suffix: / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: &L?) \ OC)" a n Chun Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Y�cav (un5�0 31 - t o l <br /> Physical Address I <br /> au 1?1 0 <br /> Inspection Date ' �/ / Q <br /> 0 uw-o-) CA 'Zin\0 v <br /> Time In Time Out <br /> Business Rep TitleO 0 AM 0 AM <br /> (� r ® PM 0P <br /> �vS1T\ Sh�t n eArArIGVrn1A1- <br /> �! Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> * Active Q Passenger 0 Generator v Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive &Truck <br /> Longitude - Q End-Use e Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair .0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl <br /> / 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 EX7) N <br /> _ _ a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 <br /> in Compliance No Violations o <br /> Q 1 Q 1 Other:§ <br /> -- z <br /> Comments � 1 t t Iv !1 -1 ( 1 0 <br /> — - - :zn�) <br /> NQ rn_ <br /> Inspection Form Included: O, (2��� - <br /> Comments Included: ® 019z t ZZ514- <br /> Business Rep's Signature Phone Number Insp&4o�ure Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E X A M P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop -L ® 0 <br />