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03 Waste Tire Su, Bey & Inspection Report -Inspection Report Number <br /> CalRecycle State of California I 1 - 1196725 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 _ � \ Inspection Type(Fill one) <br /> Site Suffix: _` 10 v 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: �jA \ / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business orFacilityName `7 Inspected By Inspector <br /> Physical Aaa eL�sS � <br /> 1 -` <br /> Inspection Date <br /> CCA_CY Time In ` Time Out <br /> Business Rep Title 0 AM I 2 1 0 AM <br /> O PM • PM <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 /> O * Active Q Passenger O Generator Q Out ti or <br /> Latitude Q Closed Q Altered to 11x1 <br /> (`aPs Q Hauler Q Indoor <br /> 0 Q Inactive 0 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 0 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 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 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 N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle v <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 is <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsT v1' A` <br /> e� <br /> Inspection Form Included: Q 2. <br /> Comments Included: 0- ' —� <br /> Bu ess Rep's nature Phone Number Inspector's Signature Phone Number <br /> n �( <br /> INSTRUCTIONS ON ACK [Correct:40 Incorrect: g E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />