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i Waste Tire St... vey & Inspection Report. Inspection Report Nurnber <br /> CalRecycle State of California I 1 - 1226351 <br /> ry <br /> CalRecycle 181(Rev. (Ca(CalRSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recoveecycle) <br /> Part A- urvey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: j �� (J -7 C 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1� � C—��' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address w3 l C) ( )Vt <br /> CA C ���(( 6 ' Inspection Date `� / / Z <br /> `F-— Time In v Time Out <br /> Business Rep Title 0 AM / ? 0 AM <br /> >� C1 ® PM — 7 ® PM <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 /> 0 ® Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ® Hauler ® Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned OTR ® End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation � Extension <br /> O O <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXTJ h <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 <br /> Inspection Form Included: 0 _ <br /> Comments Included: 6�Y673 <br /> B ess Rep's Signature Phone Number I e r s I re Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: I E A M L E1 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: LA 0 <br />