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Waste Tire S&ey & Inspection Report°Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 125585 7 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 E <br /> . <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A--Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- inspection f � � O � 14] L] <br /> � (� Inspection Type(Fill one) <br /> Site Suffix: 1I v ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L5�vs\_ QCHP QCaIRecycle 0 Complaint aint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address q - tz , L A n A 'T \ I <br /> 12`x? <br /> Inspection Date <br /> ja Time In v Time Out v <br /> Business Rep 17 L1_ e �cTitle a__\ AM f ®AM <br /> J _ 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 /> f ® Active ® Passenger 0 Generator 0 Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude DJ <br /> . Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - , LU--' J� Q Planned Q OTR Q End-Use Q Container <br /> _LLIBusiness 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 • Otherna _ <br /> apo ,_dh._Ge.___------ <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-Registrtition/Decal in Vehicle <br /> Q Q 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 EX>) N <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 /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �. <br /> ®In Compliance-No Violations <br /> Q Q o <br /> Other:§ <br /> - ---------- <br /> --- z <br /> Comments- <br /> %A <br /> ommentsto a <br /> �(Qv�ovS QC2A Cl�- &, e1,% CQrt�2 <br /> Inspection Form Included: Q r <br /> Comments Included: ® �� /3��I 4 <br /> �- <br /> Busi ess Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON7BACIK. jo : <br /> ;ec�ycle <br /> .*_Lncorrect: EXAMPLE 1 2 3 62081 <br /> ■ ® ■ <br /> ' -' Yellow Copy:Operator Pink Copy:LEA <br />