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Ins ection Report Number <br /> Waste Tire S�.. .ey & Inspection Report p � <br /> CalRecycle State of California I 1 ® 1196498 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 © { t 0 © I Inspection Type(Fill one) <br /> Site Suffix: 1 �'I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> c Q � Inspected By Inspector <br /> � <br /> Physical Address m Q <br /> �c� C� 9S 206 Inspection Date � / Z -7 / ! 3 <br /> 5 �� <br /> Time In Time Out <br /> Business Rep Title i h ®AM -*AM <br /> O PM r 2 s 0 PM <br /> caC �rcww�-� -- <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 /> I& Active ® Passenger ® Generator 0 Outdoor <br /> O <br /> GPS Latitude O Closed O Altered O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR O End-Use <br /> 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 ® OtherQ1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 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 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / Fn <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 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 /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators = <br /> •In Compliance-No Violations o <br /> O Q 1Other:§ <br /> Comments <br /> eo�S cz�c �vti+2C�- <br /> Inspection Form Included: Q Cq SYG-7zC)cf <br /> Comments Included: ® <br /> siness p s Signature Phone Number Inspe tot's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A M P L E 1 2 3 62os1 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />