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Waste Tire 4 vey & Inspection Repor Inspection Report Number . <br /> CalRecycle State of California(Rev. <br /> I 1 - 1176669 <br /> CalRecycle 181 cover (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 I Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: p2 Cf f 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: YV O CHP Q CalRecycle Q Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> MG <br /> Physical Address j <br /> .� Inspection Date e O / C) / <br /> /-�enc�•- r! �m� C� �/s�3 i <br /> Time In Time Out <br /> Business Rep e Tit] O AM Q AM <br /> vjvkv 0 ;L . A O ® PM . 3 0 ® PM <br /> /1vIne Alt p �t ave- D�� �1 y r. - -— - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 4-/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> QRS Latitude Q Hauler-- - <br /> O Q Inactive ® Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government ® 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 /> O Notice Of Violation O Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 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 EXT) N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement i <br /> O 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 <br /> O Q Other:§ <br /> Comments <br /> Inspection Form Included: 0 v <br /> Comments Included: ~ '/// " .�i�-✓'���7� r/6� �O 3 <br /> ® Business R 's Signature Phone Number Inspector's Signature Phone Number <br /> I 62081 <br /> Correct:0 Incorrect: � 'W l E X AIM IL '' 11I2I3 <br /> INSTRUCTIONS ON BACK - <br /> W ite Copy:CalRecycle Yellow Copy:Operator Pink C <br />