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Waste Tire SL. Bey & Inspection Repon Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196438 <br /> CalRecycle 181(Rev.10/10 <br /> (Ca), Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surve 1 BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Ll <br /> Site Suffix: '� [ Cl /_( 3 Ll r (01 Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: yt : y_& Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name D <br /> Inspected By Inspector <br /> 6A W e-6sk flCG c'v - - <br /> Physical Address / ( c <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' 4 '5- ®PM �L 1 'J O PM <br /> Ghn3 ✓►un s � ✓rbf�. <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 /> Q Active Q Passenger ® Generator ® Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 • 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 / m / 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 <br /> 1 b l✓, <br /> t 1 i'EI rI L t1tGAV �S <br /> a� 175 /r"-Py'5c GT- Gr,,l 01�_ cf3<4 <br /> Inspection Form Included: Q <br /> Comments Included: Q a�t� — <br /> Business Rep's Sig ature Phone Number In r`ignaftyd Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct:18 Incorrect: M � NJ EXAM E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:UVA ® ■ <br />