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Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br /> State of California <br /> CalRecycle T 1 e 1244- 943 <br /> CalRecycle 181(Rev.y(Cal S u rm // FOo r mii = Pa e I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) S V � 11 11 Il�l Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � _ O � Inspection Type(Fill one) <br /> � <br /> Site Suffix: v Routine Q Re-inspection Q Referral Q Observation <br /> Local �- I If Referral,choose referral type(Fill one) <br /> Identifier: _l 1^ <br /> J0Co <br /> u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName _ 1 Inspected By Inspector <br /> �� 1w Z_ 1S�lLS _ ` <br /> Physical Address 3 1 l (� 1 (_SCb1 � <br /> Inspection Date � / Q <br /> Time In Time Out \(J <br /> Business Rep L I_ Title O AM Q AM <br /> (LAAan k0`[G4f( Gv �CtfYl�rlq' m c_ 5 ® PM V ® 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 /> 0 Active Q Passenger 9 Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Ind or� <br /> o Q Inactive 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 /> 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 /> 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 i <br /> § <br /> *in Compliance-No Violations o <br /> Q 1 Q 1 Other: <br /> Comments <br /> Vl,� <br /> Inspection Form included: Q •' 77 <br /> Comments Included: <br /> Usines Rep's Signature Phone Number Inspuctl Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM E 2 131 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® 0 <br />