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Waste Tire Slorey & Inspection Repor0Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 -1176665 <br /> CalRecycle 181(Rev. (CalRSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(Calecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection S - U 1 Inspection Type(Fill one) <br /> Site Suffix: `-( Z ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5L1N1Fbai644� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> vno � r <br /> Physical Address 3 <br /> / <br /> / G Inspection Date Q G / 2- Z7 / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> N/ f) 0 ®PM v--/ -- a ® PM <br /> 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> ® 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 /> Q New Tire Dealer Q 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 mFT] <br /> QQ 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> r <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q O 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 /> -���>•rt-c— - ih�c.�i�-- �1n%� �Lc'1fe��lr�P�7Ll��---���-��C�.�1 �, <br /> Inspection Form Included: Q <br /> Comments Included: ® Ana 1, ----- C Z-C -70 3 <br /> Business Rep's Signatur Phone Number Inspector's Signa re Phone Number <br /> INSTRUCTIONS ON BACK Correct: ' <br /> Incorrect: EXA E 11213 <br /> 62081 <br /> D <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop Y. <br />