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Waste Tire Su. iey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196511 <br /> ry <br /> CalRecycle 181(Rev. (Ca] 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- � + Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ��� �q v�y� c%.-,�V\V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physical <br /> �Address ,1 Vto <br /> Inspection Date / 1 "� 3 <br /> Steck��n `�52bN I <br /> Time In Time Out <br /> Business Rep TitleO 0 AM <br /> 0 PM 0 PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol /PTE g o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' !Active *Passenger f Generator 0 Outdoor <br /> O Q 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 /> New Tire Dealer 0 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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 EXE 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 Q Referred/CalRecycle Enforcement <br /> Q Q 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 1 Q 1 Other:§ <br /> Commentsvc. Cc2 '�`�12 \Yyc� t CNN OV\ �� S <br /> �S <br /> Soy hN-nn� <br /> Inspection Form Included: Q �pedtor's <br /> Comments Included: 10iness Rep's Signature Phone Number Inignature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />