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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196364 <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- ,y ( _ ' *3 c� C - 0 Inspection Type(Fill one) <br /> Site Suffix: (9 cJ� J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Salk�pC��1�i.� ���1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JJJ Inspected By Inspector <br /> Zra ' <br /> p - <br /> PhysicalAtdppdre� 3 1 � � C_S�T�'� <br /> Inspection Date �,1 <br /> (a.G, I <br /> Time In Time Out <br /> Business Rep Title // /� AM a AM <br /> Lt ' V U Q PM S S Q PM <br /> Rl7�c,r� S rnnu,el'� �prT T m-S. <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 /> 'Active ® Passenger * Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 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 /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Is 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators If In Compliance-No Violations o <br /> Q Q Other:§ _ <br /> Comments n <br /> K0W Yl I <br /> a n- t-AAA., 0 j <br /> 1 Tit i U <br /> Inspection Form Included: <br /> °`1'` �0" 000 aU� <br /> Comments Included: � - - <br /> Bu 'ness Rep's Signature Phone Number Insp or's Signature lyhone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A L 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co © ■ <br />