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Waste Tire Sui Bey & Inspection Report Inspection Report Number ■ <br />cal6ecycle State of California 11 — 1196256 <br />CalRecycle 181 (Rev. y (Cal Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />parr A - Ci int axt BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -� � � <br />Site Suffix: ` � � � � © <br />Inspection Type (Fill one) <br />Q <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local 1 <br />Identifier: or V��ri �UY� \� <br />Bussiciness((o��r Facility Name <br />Inspected By Inspector <br />` <br />VIII <br />Q <br />A�ddress�\ <br />PhysiAA <br />/n � <br />1'T V <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />J�1av\�e�ca C G5336 <br />Inspection Date / 2 7 / I <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Time In Time Out <br />Business Rep Title <br />c 0 AM 0 O AM <br />d <br />Q <br />' J 0 PM J 6 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Q <br />Tire Count (Whole/PTE)' <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q <br />* Active <br />Q Closed <br />Q Passenger <br />O Altered <br />0 Generator <br />Q Hauler <br />I& Outdoor <br />Indoor <br />GPS Latitude <br />Q Inactive <br />0 Truck <br />O <br />Longitude — <br />Q Planned <br />Q OTR <br />Q End -Use <br />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`2W, <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />Comments <br />SM <br />olC Co eCY� <br />Inspection Form Included: Q <br />-,- r\�/ d 7 <br />Comments Included: <br />Business Reps Sin re Phone Number <br />� !� <br />Inspec%tors Signature Phone Number <br />�,( <br />INSTRUCTIONS ON BACK Correct: Incorrect: X� NJ 11 E X A M P L E 1112 3 62081 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® 0 <br />N <br />N <br />Lo <br />0 <br />Lu <br />Lu <br />