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Waste Tire �7urve & Ms ection <br /> _ Rep <br /> op Inspection Report Number er <br /> StateofCaliforniaCalRecycle CalReycle 181(Rev. ) page q11 - 1245123 <br /> Dept.of Resources Recycling and Recovery(CaRSuPVayF®rf <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> - Inspection Type(Fill one) <br /> Site Suffix: ` Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ;^ ��)~c C�V1y� Q CHP Q CalRecyc►e Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> z <br /> C` ���` � � Inspection Date ( <br /> I <br /> L Time In Time Out <br /> Business Rep ty Title 40 AM ]� 40 AM <br /> �� <br /> �VC�.QL✓� �1.t�1tR.' ( Z_ Q PM 1 j V Q PM <br /> / Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) y, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ° J 0 Active Q Passenger 0 Generator (] Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned f OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) YVto <br /> Q New Tire Dealer I* 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 49 Other SFU as_�, 4eula <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 <br /> 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 /> 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 <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments � L�2.�--C � .L,�2' i►-c/Z..ft�.�G✓c., G��-- ��_K.ttp, ��1, N <br /> t Gum <br /> ao�- <br /> Inspection Form Included: Q 401q-as- <br /> 1 <br /> Comments Included:® 44e>- Z <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: A W EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />