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Waste Tire Sw, dey & Inspection, Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1177781 <br /> CalRecycle 181(Rev.folio) 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 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: C ��h� �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /// Inspected By Inspector <br /> 76A ztjhei�1 Lac_Mt� <br /> Physical Address ��� J) <br /> q Inspection Date (_/ <br /> 2qo <br /> Time In Time Out <br /> Business Rep Title ® AM d'AM <br /> 5- <br /> ` �,v Q PM I S O PM <br /> /rp &L r•'CNe ` Y/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger 4b Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned If OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 /> 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 /> 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) <br /> a <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 /> 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 <br /> In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> i <br /> Comments ` <br /> N <br /> Inspection Form Included: O <br /> Comments Included: <br /> Bu ' Signature Phone Number eVr' gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �V]JE X A L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />