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Waste Tire Sup Bey & Inspection Report Inspection Report Number . <br /> CalRecycle State of cle 181(R I 1 - 121016 3 <br /> CalRecycle 181(Rev.y(Ca) Survey Form - Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V � FY <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 <br /> L, k, o © Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: QCHP QCalR�CalRecycle 0 Complaint Q Educational Visit QOther <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A\w\ c�,� 5 <br /> Ad 1 ire- `rte °I - 01 MAT--` U <br /> Physical Address <br /> 2?B S W- <br /> IC <br /> - a <br /> Inspection Date 3 <br /> —1f t - CA °IS3A`� <br /> Time In Time Out <br /> Business Rep Title 9 AM O AM <br /> r, -- - --- Z O 0 PM ®PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 -2 ® Active O Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler e Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 1 Other:§ <br /> Comments �pcY\ �S—C�C.��R <br /> `2 ° <br /> �oK �Vt Ck M)A C C—q-v N, <br /> Inspection Form Included: O <br /> Comments Included: � '� � 2C�^���` <br /> Business ep's ignatur In <br /> Phone Number spe or's Sig ature Phone Number <br /> ---------- - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g EXAMPLEI 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />