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Waste Tire Ste & Inspection Repo Anspection Report Number <br /> CalRecycle State of California Y _ — 1245227 CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form Page 1 I112 4 5 2 2 7 <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 / _ C� /^ - Q Inspection Type(Fill one) <br /> 0 J <br /> Site Suffix: l0 Y <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �C q !J l o L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> r Inspected By Inspector <br /> 7ivL Tr <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Bu."iness Rep Title J AM �, AM <br /> l 7 <br /> QPM ' . V QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 !� (� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _J / 9 0 Active 0 Passenger 0 Generator e Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive S Truck <br /> Longitude - Q Planned OTR End-Use 0 Container �0 <br /> Business Type(Fill all that apply) <br /> J New Tire Dealer Auto Repair Q Trucking Fleet Q Government , Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 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 • 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 l�- ILylpx& 7b l <br /> V <br /> Inspection Form Included: Q <br /> Comments Included: S — �Z� <br /> Business Rep's Signature Phone Number AInspector's ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V E X A M P L EF_]� J � J � JJ � 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />