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Waste Tire Sull Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1177738 <br /> CalRecycle 181(Rev. (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- Inspection Type(Fill one) <br /> Site Suffix: Fi ( 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ✓ If Referral,choose referral type(Fill one) <br /> Identifier: r.�, 60M 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical dd�re sl _7') <br /> � I Inspection Date � <br /> / / / } <br /> `" ' g5d,`� Time In Time Out ! <br /> Business Rep Title - I ® AM O AM <br /> O PM J O ®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 /> J ® Active 0 Passenger 0 Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive (aTruck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FH <br /> / M , m a <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Z <br /> Comments <br /> cSZ'� CC1�111�1�_ M <br /> Inspection Form Included: 0 <br /> Comments Included: ® -64-f687 <br /> _ B s ess Rep's Signature Phone Number I ctor' natur Phone Number <br /> INSTRUCTIONS ON B CK Correct: Incorrect: zs� W E X A JJ4'Ej 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink&. <br />