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Waste Tire Su. dey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - <br /> CalRecycle 181(Rev.y Ho) 1230376 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form o (gage 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- tA S 5. _7 5 ^ � O ' Inspection Type(Fill one) <br /> Site Suffix: ") I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Y\ W V nNV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 2$ 3�o A,-Ac, ''\a2ox_ Wcl S\4-- 1 <br /> � <br /> C� Inspection Date <br /> ctvy 1S�� Time In Time Out <br /> Business Rep Title 0 Al 0 AM <br /> � PM * PM <br /> 0�, Qi��GY�ClS —CQ � � <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 /> 40 Active Passenger 0 Generator Q Ou opr <br /> GPS Latitude Q Closed Q Altered (// <br /> Q Hauler Q Indoor <br /> O Q Inactive Q 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 Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer i 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <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 /> LU <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 1 Q 1 Other:§ <br /> Comments �� oe���`— \_�- <br /> 'Ca 'tG�'T^` V <br /> cwc S <br /> Inspection Form Included. �(`� `/���„lq , J�'�,�� �b •^���^�� <br /> Comments Included. v UU <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: zQ � q E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />