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Waste Tire St.. Bey & Inspection Report Inspection Report :Dumber <br /> CalRecycle State of California 11 - 1210541 <br /> CalRecycle 181(Rev. (Cal Survey Form - Pale <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � f � � <br /> b � Inspection Type(Fill one) <br /> � � <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local T ` If Referral,choose referral type(Fill one) <br /> Identifier: ,V1jh Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 1�oo . . - <br /> Inspection Date 9 / 2 9 / � 3 <br /> S Glc�o,r� C q S ZoS <br /> Time In Time Out <br /> Business Rep Title 1 � � �\" we :AM � � A � AM <br /> M �j � PM U � PM <br /> �C�� ( 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 /> ! Active Q Passenger 9 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> � GAS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive ! 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 • Other TpLAV 52cVtC-2 <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler qnd 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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q • 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> Inspection FormIncluded: Q <br /> Comments Included: <br /> Busine s I ature Phone Number Inspe tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g EXAMPLE 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />