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Waste Tire Su. ojey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210491 <br /> CalRecycle 181(Rev. (Cal 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- e � � � � � - © 1 Inspection Type(Fill one) <br /> �Site Suffix: ` J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ♦ 1 If Referral,choose referral type(Fill one) <br /> Identifier: SIfAl _ o G L1'!1 CO <br /> O>1�1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name II Inspected By Inspector <br /> (�\d ds C ry n� I f-',4j5FV f t <br /> Physical Address EV J J <br /> qS <br /> T1 C'\f �� �5��, Inspection Date <br /> l• A Time In Time Out <br /> Business Rep Title : � 0 0 AM 0 0 AM <br /> `�lAr ® PM V (0 PM <br /> {, b>~S� 7 <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 ® Passenger IS Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude , . Q Hauler ® Indoor <br /> O Q Inactive 0 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 • 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 Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Fp / m / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle U) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 Q 0 1 fhlS G <br /> � n0 <br /> N1 _&&I 0_(As <br /> Inspection FormIncluded: Q <br /> Comments Included: ® R;eAA'Pr� <br /> Business Reps Signature Phone Number Inspec 's Signaturember <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A P L E 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />