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Waste Tire Sup Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226634 <br /> CalRecycle 181(Rev.y(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 Type(Fill one) <br /> Site Suffix: l U eft 5 C1 V ® Routine Q Re-inspection Q Referral Q Observation <br /> Localcc �(,`,�� / If Referral,choose referral type(Fill one) <br /> Identifier: J G� �: _ vt/� -�L�vr 1. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> F—sC'C'Jcy Tri <br /> Physical Address t 1 <br /> Inspection Date <br /> �-C�1cN1 <br /> CA R573vl <br /> Time In Time Out <br /> Business Rep Title } 0 AM 0 AM <br /> ' 0 PM f 2 a QPM <br /> Operational Status .Titre Type Business Role Storage Type <br /> Tire Count(Whole3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / TE v <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive � Truck <br /> Longitude - ® OTR ®End Use Container <br /> Q Planned <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q 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 <br /> 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 I <br /> Q 014 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 z <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Sy �D e ti N <br /> Inspection Form Included: Q / <br /> Comments Included: <br /> Business Rep's Signat Phone Number In _ tor's Ig ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X V E X I A M P L E 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />