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Waste Tire SLAey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245239 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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� � � � � Inspection Type(Fill one) <br /> � � <br /> Site Suffix: $ , Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� J rte; V� <br /> Business or Facility Name """q Cc, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> 7 7 Inspected By Inspector <br /> Physical Address <br /> q5;253 Inspection Date O Q 1 S <br /> S ocic-�o C <br /> Time In Time Out <br /> Business Rep TitleZ O AM O AM <br /> � S WPM � ' � ® PM <br /> .LSSA C_ C0. dS A Mnt r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) A (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> U@ Active 0 Passenger 0 Generator * Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned 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 •Other 6;rC'j0_4c v h6vis�bG LI <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 M / m / 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 EXE 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 /> 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 Q Other:§ <br /> Comments \P__ <br /> I�O .N CW CLS V:r CP_ gA(�r A <br /> W� <br /> �. c r <br /> Inspection FormIncluded: Q <br /> EN <br /> Comments Included: ��111 � <br /> siness Rep's S nature Phone Number Insp or <br /> 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop' :LE <br />