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Oa Waste Tire SL_ rey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle - 1177997 ■ <br /> CalRecycle 181(Rev. (CalRecycle) <br /> Survey Form - Page 1 I 1 117 7 9 9 7 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y 5 O_ / Inspection Type(Fill one) <br /> Site Suffix: I u 1 <br /> Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> S c,n �Q �/�)n W L� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Avc-- <br /> 6 C � � Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> 1 /l 0 A ® AM <br /> llac o r �11(n�I� I t� U�y(�U r V(1 V O PM D O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C� �j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> If Active 10 Passenger g ® Generator Q Outdoor <br /> GPS Latitude 0 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude <br /> • Q Planned Q OTR 0 End-Use ® 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 9 Other k,S <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 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 Exr) N <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 <br /> 0 Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> LU <br /> O 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 /> All (����o s— �� U� � �_UIL (< )) - <br /> _ <br /> Inspection Form Included: Q <br /> 410-0g05 <br /> Comments Included: Q Q 1 Q <br /> usiness Rep s Signature Phone Number Inspe t is Signllure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g E X AE 2 1 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y:L ® ■ <br />