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Waste Tire St... ,✓ey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 — 1 1 1 (� /! jN 1 <br /> CalRecycle181 R(Rev. y(Cal Survey Form - Page 1 1 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- (_ I l Q O - I Inspection Type(Fill one) <br /> "t <br /> Site Suffix: lU c� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: 5G� u.,r\ � � Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> GcnI e an�� ( SJ['�'N q _ (� <br /> Physical Address 1 I v + 1) G�,10q-D <br /> (,b car);F) 5� . <br /> � 'iInspection Date <br /> C 6 C�(o <br /> Time M Time Out <br /> Business Rep Title l ® AM O AM <br /> o LO ' l S O PM S ® PM <br /> --- Operational Status Tire Type Business Role Storage Type <br /> Tire COunt (Wliole/PTE) r_ /1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �D lJ ® Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> O Q Inactive Q Truck Q Hauler ® Indoor <br /> Longitude - Q Planned 0 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 EIt 40\4 } QzW.J3"011e <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 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 /> Inspection Form Included: Q <br /> Comments Included: <br /> 4Bulne"ep nature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � E X A M P 1 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />