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N <br /> Oa Waste Tire Soey & Inspection Repor ,, Inspection Report Number <br /> Cal6ec cle State of California p <br /> Y CalRecycle 181(Rev. (Ca[ I1 - 1245230 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page I <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /( Inspection Type(Fill one) <br /> Site Suffix: ' `T &Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Y� � QC ()�I/( C�il.t�,<. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> BurO <br /> ess or Facility Name Inspected By Inspector <br /> C`o�� X30 Co. <br /> Physicc'al Address <br /> f1 tbd C it- /S r � Inspection Date <br /> "/'f �[J Time In Time Out <br /> Business Rep Title 0 AM wpmI L 6 � PM <br /> 0 AM <br /> bad wcfizt'I'k'e_ <br /> �. Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude <br /> O Q Closed Q Altered Q Hauler Q Ind "r Ar l—Ol <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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / 7 Q. Q 14 CCR§18459.1 Tire Program ID Number from CalRecycle I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q 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 = <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> u <br /> h6b <br /> NO <br /> v�2 - <br /> Inspection Form Included: 6&P-1-5 <br /> ]D17Comments Included: - / / <br /> Bu s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: � � g EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CopLE ® ■ <br />