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Waste Tire Skey & Inspection Re ort Inspection Report Number <br /> Cal Recycle State of California Rep <br /> on <br /> 181(Rev. (CalRecycle) Survey <br /> I1 - 11761121 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection t Inspection Type(Fill one) <br /> O <br /> Site Suffix: t l ® Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f cyl GnLA, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> DO I,- 1'9AC 'Cy_ f-'O vcx s <br /> Physical Address (� j 9 Q <br /> t <br /> Inspection Date O <br /> c,1c�-a�n Cts �rs�s' <br /> Time In Time Out <br /> Business Rep Title 0 ® AM _ Q AM <br /> �/,4 �p Co , n QPM � � U � I® 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 ® Generator Q Outdoor <br /> GPS Latitude 0 Closed 0 Altered <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) i /W#A <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 0 Hauler Q Agriculture Q Shredder A 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 /> ----- 0 Notice Of Violation Q Extension i <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Other:§ --- -- -- <br /> Comments <br /> Inspection Form Included: 0I' r/ 2.2-7— <br /> � �6 <br /> /1 <br /> � Comments Included: <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: +� E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />