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Waste Tire Sug vey & Dn,spectiOo n Repori i Inspection Report Number <br /> CalRecycle State c California I 11 - 1242191 <br /> CalRecycle 181(Rev.y(Cal Survey/ Form — Page Dept of Resources Recycling and Recovery(CalRecycle) 'Id� V�i �i <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection p r Inspection Type(Fill one) <br /> Site Suffix: j <) ( C ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - �'� � ✓1�\ �- L yL 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address , -7 <br /> r Inspection Date Time In Time Out <br /> Business Rep Title AM r (P AM <br /> f� O PM 1 I Q 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 /> V Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude O 0 Closed 0 Altered O Hauler 0 Indoo/a <br /> Q 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other ` <br /> '.- ( I (LJ IL) .4-C-:!—!,4')'�! <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) A <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> 7 N <br /> Inspection Form Included: <br /> Comments Included: <br /> _ <br /> LOSL Phone Number n e tor's gn ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: I EjxjAjM 11213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L ® ■ <br />