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Waste Tire 5 ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 12 4 5 2 8 5 <br /> ry <br /> CalRecycle 181(Rev.y[Ca(CalRSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recoveecycle) <br /> 31art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � � - � r Inspection Type(Fill one) <br /> Site Suffix: \` &Routine Q Re-inspection Q Referral O Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: f�`n U r Q CHP Q CalRecycle Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J � l 0 `C � � <br /> Inspection Date / 1 9 / j S <br /> ime In Time Out <br /> Business Rep Title 6 -30 <br /> SAM SPAM <br /> "�� � QPM � � � `�O QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count hol /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 7-7e Active Q Passenger a Generator 16 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude Q Planned ® OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) r11pj C eLQ_ <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Omantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O 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 /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> O O Other:§ <br /> Comments l9� 0 cQ) `` _ ,_ „ ci-L_ 4_ i � „ N <br /> U0 C-C <br /> Inspection Form Included: O `^6C /,/ `o <br /> Comments Included.® .- <br /> 46 <br /> siness Rep's Signature Phone Number Inspe tor's Signa'afure Phone Number <br /> � <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />