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Waste Tire Ste. Bey & Inspection Repot . Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1176474, <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _ BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- u Inspection Type(Fill one) <br /> Site Suffix: ' l V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �,^•• \ N-\(\ <br /> , / If Referral,choose referral type(Fill one) <br /> Identifier: Xl\ J�. IC:¢��-\ �, 1�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address S A-tz:,YylbL. <br /> Inspection Date 1 i <br /> Time In Time Out l <br /> Title AM f 2 ®AM <br /> Business Rep I Q : 5 0 0 PM ! I �J O PM <br /> L a��►� r e. �ievRns �l ��1aftiIz 6 <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> f � ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <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 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 N <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 , 0 Other:§ <br /> Comments <br /> N <br /> Inspection Form Included: Q <br /> Comments Included: � JEA <br /> t�p <br /> —u es ep's Signature Phone Number gn re Phone Number62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: L 1 2 3 <br /> ■ WhiteCopy:CalRecycle Yellow Copy:Operator Pink Co " © ■ <br />