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Waste Tire Sui dey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1242268 <br /> CalRecycle 181(Rev. y(CalRecycle) Survey <br /> 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- � ,Z �7 � � � n _ � 1 Inspection Type(Fill one) <br /> / <br /> Site Suffix: ` O Routine O Re-inspection ® Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �QY1 �URQ �v,� O CHP O CalRecycle I*Complaint O Educational Visit O Other <br /> Business or Facility Name --1i Inspected By Inspector <br /> `T'�ce� \��e5► � �-ecY�\RcS, Tic. - 11 <br /> Physical Address C) <br /> 6`'131 � C-l�•c�ok-e-e <br /> S�OC�f-� Inspection Date b 2 / 03uf � I <br /> Time In Time Out <br /> Business Rep Title t AM AM <br /> 0 5 0 PM 1 O ' 1 O PM <br /> 70��` :co.x� C>wv�et <br /> Operational Status Tire Type Business Role Storage Type <br /> L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 6 <br /> Tire Count(Whole/PTE)) 5 0 0 Active 0 Passenger O Generator 0 Outdoor <br /> O Closed O Altered <br /> GPS Latitude 0 Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture O Shredder O 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 /> 0 Notice Of Violation O Extension <br /> O O <br /> PRC§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 1 <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date�]17— M25 <br /> / 1 <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 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 O In Compliance-No Violations o <br /> O O Other:§ <br /> Comments ,` <br /> 01-1 <br /> Inspection Form Included: <br /> Comments Included: !� <br /> Business Rep's Signature ne Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: X � E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />