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Waste Tire Ste & Inspection Re ortOnspection Report Number <br /> CalRecycle y p _ p I 1 - 1242523 <br /> State of California <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 1 Inspection Type(Fill one) <br /> Site Suffix: S (Q 1 1* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S ox-) �� �� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> (�' �] (� Inspection Date I ' (� <br /> �o � �� v �S""D Time In I Time Out 1 <br /> Business Rep Title S O 0 AM 0 AM <br /> 4b PM � � � ® PM <br /> S� Mov)( <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 /> Is Active 0 Passenger 48 Generator • Outdoor <br /> 0 Ck*W 0 Altered <br /> GPS Latitude 0 Hauler 10 Indoor <br /> O 0 Irtactwe 4b Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 9► der Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Howler and Es+d-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Maneesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments � � 1AlAc N <br /> GA � {> �' <br /> NI 10nS. b� CA f 1.+5 (j+ civix"r o <br /> Inspection Form Included: 0 ' R <br /> 0 <br /> Comments Included: � � 7 — ���51�" <br /> Business Rep's Signature Phone Number Ins tor's Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M ' L1 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />