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Waste Tire Sul, vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of cle181California I 1 - 1196271 <br /> CalRecycle 181(Rev.y(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- inspection� � 2 v � 1 Inspection Type(Fill one) <br /> � � <br /> Site Suffix: 1 10 ® Routine Q Re-inspection Q Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: k 0'®GLC % co u�V� O CHP Q CalRecycle Q Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 307 Md �3 vi'�o� <br /> Inspection Date � � / "] 2 <br /> 5��v�� CA 9'5z(!)'5 <br /> Time In Time Out <br /> Business Rep Title g 10 AM AM <br /> C\' 0 <br /> C\'� 1 Q PM J Q PM <br /> DVC`n5 <br /> -- Z1 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 /> ie� 9 Active 0 Passenger 0 Generator Q Outdoor <br /> - <br /> O Q Closed Q Altered 40k <br /> GpS Latitude Q Hauler 0 Indoor <br /> o Q Inactive 0 Truck <br /> Longitude — Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) �0 4 <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other �jaoJS2�� � CenC <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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m m <br /> O Q 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 Ex>7 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 O Other:§ <br /> Z <br /> 6 <br /> Comments <br /> c y-\ <br /> Inspection Form Included: Q <br /> Comments Included: `C Cht7 <br /> B si ess nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON ACK Correct: Incorrect: EXAMPLE 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />