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Waste Tire Survey & Inspection Report .nspection Report Number <br /> CalRecycle State of California I 1 _ <br /> CalRecycle 181(Rev.y H0) 1242142 <br /> r-vey Form - Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) S lei <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 6 $ Q �j 0 l ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C"My1, , GQr O CHP Q CalRecycle O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> G-'i l h e'j <br /> Physical Address 9 c1 - L 0 ) ��)Am )g l�i- <br /> Inspection Date l� / 9- 6 / C <br /> Time In Time Out <br /> Business Rep Title ®AM ? &AM <br /> ) I • U Z QPM ( J U OPM <br /> &it lG' OL4,YW.,- <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 O Passenger ® Generator ®Outdoor <br /> O <br /> GPS Latitude O Closed O Altered <br /> O Hauler O Indoor <br /> O O Inactive 0 Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> O New Tire Dealer O Auto Repair ® Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance-No Violations o <br /> O 1 O 1 Other:§ <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business Rep's Signature Phone Number In p t r' S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X4 V I E I X A M L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />