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03 Waste Tire Su. Bey & Inspection Report inspection Report Number <br /> CalRecycle Cilie of California 11 - 1230262 <br /> CalRecycle 181(Rev.y(Cal. Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A--Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 2 $ 2 O 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q��n �R Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address - M '-�T4T V <br /> Inspection Date I 2 / ` 7 <br /> Time In Time Out <br /> Business Rep Title Cr`` O AM 0 AM <br /> � O 0 P I 0 P <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(V11holPT <br /> ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 <br /> 0 Active Q Passenger 49 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor � <br /> O Q Inactive O Truck <br /> Longitude - Q Planned Q OTR Q End-Use • Container ly <br /> Business Type(Fill all that apply) _ <br /> Q New Tire Dealer (5 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 �� <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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires o <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal it Vehicle ® 1 <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EX7) N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments .�1. <br /> �a.S�'. � � 1hS�.���► off— �. �1�... c eJ� <br /> i\' <br /> 6 0 <br /> Inspection Form Included: y / ' Z o y <br /> Comments Included: ' � �©,O(s- <br /> - Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: E X A M P L E l l 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />