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Waste TireAey & Ins ection Re or , Inspection Report Number <br /> CalRec cle p p - 1245335 <br /> Y State c California I 1 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- i Q 7 1 v Inspection Type(Fill one) <br /> Site Suffix: I 1 G— l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: ()(Y-) C'at,zn� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T6ucQ l L'mea-•, '6 - 1 o <br /> Physical Address <br /> Inspection Date $ / S_ <br /> Time In Time Out <br /> Business Rep Title0 AM z �l" 0 AM <br /> VV 3 . Z Q ® pM 3 —1 � �PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appl <br /> Tof / y) <br /> I <br /> ' ' ®•Active Q Passenger Q Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 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 /> 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 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / T <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 o <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 7��-�Z��Q� /�.,_ _lC->-tA- G%CC�-GF N <br /> PUv�c <br /> Inspection Form Included: Q / 20` <br /> 9_n- � <br /> • L� ti <br /> Comments Included:® <br /> Business Rep's Signature Phone Number Inspect is Signature 47&Y-4Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />