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0 Waste Tire SL. ,iey & Inspection Repon Inspection Report dumber <br /> CalRecycle State of CaliforniaCalRecycle 181(Rev. I 1 - 1177534 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> -Part A-=Surve - - BLUE-OR-BiAC-K INK PEN <br /> Business Profile Inspection Details <br /> TPID- t O t Inspection Type(Fill one) <br /> Site Suffix: 1 C) Z g 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r� If Referral,choose referral type(Fill one) <br /> Identifier: 5&r\ JC �V�h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> SSS M . <br /> Inspection Date <br /> M-01_nk�c� c-A- G 533 J <br /> Time In Time Out <br /> Business Rep Title O AM 2 O AM <br /> � ( S ® PM O is PM <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 /> f Active 0 Passenger 0 Generator 1@ Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 /> Q Used Tire Dealer Q Auto Body 0 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 /> Q Q 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 <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 .In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments qQ ,� o <br /> e.tsy.�i r Q. �,�n Q cit-ten r�P '�hi,S C�� ari Cly <br /> - <br /> � <br /> W0.S - <br /> Inspection Form Included: O <br /> Comments Included: -- - <br /> _ usin s ep's Si ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Coflect: Incorrect: � 6& �j EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />