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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle ( <br /> State of California I 1 m 1210562 <br /> CalRecycle 181(Rev. (cal 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: I 06 0 © 49, 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local aO If Referral,choose referral type(Fill one) <br /> Identifier: �6t/Vl. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((( Inspected By Inspector <br /> A Grl L= ,)AtO ANO auPPLV --4n(-. �; <br /> Physical Address - [ �41-16 <br /> I_ p Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 61 A ) • -5 O PM 2 ® 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 /> Q Active Q Pa <br /> Vengeer ® Generator Q Outdoor <br /> o <br /> GPS Latitude e Closed Q Altered Q Hauler Q Indoor <br /> A114 <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 /> Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other 1 sup�l� <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) 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 /> W <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 ` <br /> Inspection Form Included: O <br /> � Comments Included: <br /> i r�CUT70 C7 --Z7 <br /> Business Rep's nature Phone Number spe or's gna re Phone Number <br /> - .11 62081 <br /> INSTRUCTIONS ON BACK C rect:0 Incorrect: JEjXrAjMjP [fjEj 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />