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Waste Tire Su. ,iey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1210381 <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- _ O Inspection Type(Fill one) <br /> Site Suffix: 1 l b 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local5 �. /� 1 If Referral,choose referral type(Fill one) <br /> Identifier: 01..E J��V �}v�`�/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name iii Inspected By Inspector <br /> �__Vmy\k C. AIV5rc ey�-Q 6\4'�Y5 \j <br /> Physical Address M <br /> 5 Loo W <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title M &AM I ' c O AM <br /> Lj� 0 0 PM J 0 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 /> 40 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 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 <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 Q Other:§ <br /> Comments ; Q _ c'y\ b N <br /> See Cojmw�e6� <br /> Inspection Form Included: 1111, <br /> Comments Included: <br /> Business Rep's Sign ure Phone Number Alnpecis Signatureq4 Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: NJ JEJXJA�M� PJLJEJ 1112N 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />