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Waste TireMey & Inspection Rep"Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1255773 <br /> CalRecycle 181(Rev.y(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- � Q � O � t � � _1 U ( Inspection Type(Fill one) <br /> Site Suffix: p t I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V n e O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> T6 ,cam,►-.� <br /> Physical Address 3 <br /> C A— `w Inspection Date / Q Z / <br /> J Time In Time Out <br /> Business Rep Title O AM -7O AM <br /> ' ® 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J Z_ 0 Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® 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 /> Notice Of Violation Q Extension <br /> O O 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 /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 /> Comments lyazis, tE la lrL.�cn a_,a�Y <br /> CJD C <br /> Inspection Form Included: Q <br /> Comments included: <br /> usiness Rep's Signature Phone Number Inspector's Signa1W Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X *;l q I IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />