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Waste Tire ` .vey & Inspection Repc►. 1, Inspection Report Number ■ <br /> CalRecycle State of California 11 -1176439 <br /> CalRecycle 181(Rev.y(CO) 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 /> DSite Suffix: I 5 5 V Q Routine ® Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: � (:t ��� �I U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A t� � ►� 3 - o I t>�-, <br /> Physical Address <br /> g k'[t5' <br /> C� ��� —1 <br /> Inspection Date 3 L� <br /> l l <br /> Time In Time Out <br /> Business Rep Titled ) ® AM /r� 99 AM <br /> ! <br /> �✓1 �I � ���Wr v�ir 0 � U O PM ' � V � O PM <br /> - -- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) y,- <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4D Truck <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 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 /> Q 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 N <br /> r <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 /> 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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> S) tj N <br /> Inspection Form Included: Q <br /> z <br /> Comments Included: ®.isineOs <br /> kep, <br /> - - �CfI"alb(�l6> 7gnature Phone Number Inspe r' Signatu Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A L E 1 ; 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink64A_,� © 0 <br />