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Waste Tire Su, dey & Inspection Repor' Inspection Report Number M <br /> CalRecycle State of California I 11 -1176409 <br /> CalRecycle 181 Rev. (Ca 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- I 1 1 I - Inspection Type(Fill one) <br /> Site Suffix: `1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: S(k(� J oalUt r1 Gtk )kk A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> f as W v, 2 <br /> Physical Address &n <br /> a%V h k\)C n'- (Zc� <br /> �Sa15 Inspection Date 7 / `7 I l <br /> L��D Time In Time Out <br /> Business Rep Title [[ 0 AM 0 AM <br /> 1 1 <br /> I J B PM PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 ® Other '4ej t t L(n Lt+(4c, M`, (- <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ L 11 <br /> Comments S(1Ai 0 W Zf •l ' T� ' (1 I U T <br /> Inspection Form Included: Q LG�f-�3✓ 'y�� <br /> Comments Included: ®Ausiness Rep's Signature Phone Number Inspe is Signature hone Number <br /> ------- - �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � �J E X A P E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />