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Waste Tire SL. ✓ey & Inspection Report Inspection Reporc Number ■ <br /> State of California <br /> CalRecycle I 1 - 1242171 <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- � � Inspection Type(Fill one) <br /> O <br /> Site Suffix: 46 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50,v\ ��Qy v` C3 Q CHP Q CalRecycle O Complaint O Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> PhysicAddresss Moir C1 t 1 — ' C) 1 v <br /> Inspection Date O 7 <br /> S�ock ,�n gS21S <br /> Time In Time Out <br /> Business Rep Tittle^ (' S 'AM AM <br /> J ' �QPM -2, � O PM <br /> S Operational Status i Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fdi alt that apply) (Fill all that apply) (Fill all that apply) <br /> 7 •Active 0 Passenger •Generator 0 Outdoor <br /> O <br /> GPS Latitude O Closed O wed O Hauler Q Indoor <br /> O Q Inactive O Tnck <br /> Longitude — Q Planned OTq O End-Use Q Container <br /> Business Type(Fill all that apply) _ <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreadw O Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber _\ <br /> O Service Station Q Hauler Q Agriculture Q Shredder 0 Other U1p ,� S� S �f2S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS.. <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> O O PR - — Q Notice Of Violation O Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O 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 EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O 0 Other:§ <br /> Comments <br /> _kN'Q___0\�aW��R kj,�ZCL_s )rL 0�� <br /> cnc c S o� Gsy�, eG <br /> Inspection Form Included: Q O(�j <br /> Comments Included: < < <br /> sine,. Reps nature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />