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Waste Tire S` tey & Inspection Repor `inspection Report Dumber <br /> State of California <br /> CalRecycle T 1 —1176675 1 1 6 6 5 <br /> CalRecycle 181(Rev. (CalRecycle) Survey Form - Page 1 1 / r <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE-OR-BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y r i _ ( Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Say V'--, ,yw�fr-cam Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name u Inspected By Inspector <br /> �ic h,uLa-r /,tic�,e;nJ <br /> Physical Address �% l <br /> 13a�i2i l� tt7 <br /> 1 Inspection Date <br /> �S GiG�Z'FiV-- C i'T �S ZC7 1 <br /> Time In Time Out <br /> Business Rep Title 2 O AM O AM <br /> 0 -) ' J 0 ® PM j ®PM <br /> --- -- -— -- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ° J ® Active Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> .- ... .. _._ <br /> V T 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 /> / / <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date FT] m <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 EXT) I N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Ul <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 Other:§ <br /> 10 1 - - <br /> Comments <br /> hokeel -- - <br /> Inspection Form Included: Q <br /> Comments Included: ® yb�sdb 3 <br /> Bus Hess Rep's Signature Phone Number Y nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:1@1 Incorrect: E X A M L E 112, 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cy:L <br />