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Waste Tire Sull Bey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196737 <br /> CalRecycle 181(Rev. (Cal 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- � � ^ 5 5 9 � - 01 <br /> 1 Inspection Type(Fill one) <br /> Site Suffix: `') * Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: !ck-h Te)—a-st <br /> 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ,-\ Inspected By Inspector <br /> Z q - 1 C) l T� V <br /> Physical Address <br /> CX Inspection Date / -2 I / I 3 <br /> Y <br /> cr��ogs2o7 1 <br /> Time In Time Out <br /> Business Rep Title t IIIII AM O AM <br /> 1 <br /> rV Q PM I Q PM <br /> �� L� eG�c1�V�� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 7 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Aev5es <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle q <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments + <br /> \&gagoz <br /> Inspection Form Included: 0 ' <br /> Comments Included: n .r- <br /> Business Rep's Signature hone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: � 7k 62081 <br /> EXAMPLE 1 2 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />