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Waste Tire Su, Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177766 <br /> CalRecycle 181(Rev.y(Ca), 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 `( ­7 0 , <br /> 6 l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: l-Mw \ 0C41rt l/lv� moi, -h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T Inspected By Inspector <br /> Physical'Addresr s r j <br /> P5.3-3 <br /> y Inspection Date <br /> P <br /> V tU✓L t"GGC'`- V'� 533� Time In Time Out l �J <br /> Business Rep Title ~� P O AM u O AM <br /> �UlCI`rf/ T'✓t,.nS 4-- -L '-A a ® PM -S -1 ®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 /> ® Active Q Passenger (D Generator Q Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Ind <br /> o Q Inactive ® Truck Q Hauler Qoor <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 ® Other yt c� ► j� o� <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFOR EMENT 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Ext) <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 /> 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 (a In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Include '7 <br /> usiness Rep's Ignature Phone Number 1 p tor' ig ature Phone Number <br /> INSTRUCTIONS ON BACK �COII`rect:0 Incorrect: EXAM L 11 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® E <br />