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Waste Tire tSLa, ve & Inspection Re AtInspection Report Number <br /> CalRec cle Y p _ <br /> State of California �q <br /> Y CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey For!'Yi1 o page 1 � 1245110 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) �sr ��Il Page��ii IIOJJ <br /> Part A - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -- r Inspection Type(Fill one) <br /> Site Suffix: ' 7 l� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier. 5&n of r) C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> rcw'ru'& t) I <br /> Physical Address ` ® �� <br /> Inspection Date <br /> -T nRep <br /> CA- cry3-r -_ Time In Time Out <br /> Busin /�� �� �y Title] !�f �, O AM *AM <br /> S hV,n La rhynQYp-V 1�; -I ir�� ( lJo PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire CountCho)/PTE) 1 <br /> Active Q Passenger 49 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude — Q Planned Q OTR Q End-use ® Container <br /> Business'Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT TUS <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 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 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 /> uj <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:§ I I <br /> Comments TC:�;►�. <br /> r <br /> j Inspection FormIncluded: Q <br /> Comments Included: ® � � ~ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® 0 <br />