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Waste Tire Say & Inspection Repoi spection Report Number <br /> CalRecycle State of California 11 1176541 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-SU <br /> rve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ? D Q 8 - Inspection Type(Fill one) <br /> Site Suffix: J / Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: .�O�qy�,t C"4n <br /> Q CHP Q CalRecycle Q-Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> 1:7vic . <br /> Physical Address :; C� - <br /> p <br /> Inspection Date o ✓Z / C-� 3 / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> Z 3 0 ® PM Q � a 0 ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q 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 /> _—- - <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 / FT] / FTI <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 EX7) 12 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 1 Q Other:§ -- <br /> Comments <br /> Inspection Form Included: Q 06 Z <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number -Inspector's Signature Phone Number <br /> ot <br /> INSTRUCTIONS ON BACK Correct: Incorrect: \/ �_��j I E I X A M L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />