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Inspection Report Number <br /> Waste Tire Sty. ✓ey & Inspection Report � <br /> CalRecycle State of California I 1 - 1196549 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 ^ - 1 Inspection Type(Fill one) <br /> Site Suffix: L • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 20x" �700A V;,^ Co VVNV_ O CHP O CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address MT <br /> 2 I o co VV\VV\ p—VIC-19— av e <br /> Inspection Date 0 t l / I 3 <br /> �� ��331C Time In iii' Time Out <br /> Business Rep Amr&/\ 1 q��et� Title /kSSJ f 1W` p� 0 AM0 AM <br /> * PM O � � A PM <br /> Spm Se�.:oC p'6S`�• `• <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 <br /> Tire Count(Whol (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> /PTE ` <br /> ® Active 0 Passenger * Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 I HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / IT / m <br /> O O 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 E)C7) N <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> N <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 /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IS In Compliance-No Violations o <br /> O O Other:§ <br /> Comments��\ <br /> Inspection Form Included: O 20 c y�p. <br /> Comments Included: ���7 <br /> usiness Rep's Ignatur Phone Number inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />