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Waste Tire Su, Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196469 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BL <br /> Part A - SurveyACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � -7 � � Q � � _ O 1 Inspection Type(Fill one) <br /> Site Suffix: l I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa,Y\ J'Cja12 �v N� � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0-\V,n `�ot�(e r '��nca I d 1 <br /> Physical Address � 1 <br /> Inspection Date I / 1 S / I <br /> CA gsvo <br /> Time In Time Out <br /> Business Rep Title 1 I '�, S M 0 AM <br /> QPM ` � � d 0 PM <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 /> • Active Q Passen er Q Generator Q Outdoor <br /> O Q Closed Q Altered A) <br /> GPS Latitude ® 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber ` <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder • Other Fkta ��bN i'ra Cc�o30.� <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 /> 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 I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXl) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years U) <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 •In Compliance-No Violations o <br /> Q Q Other:§ \ <br /> Comments,e-, <br /> � �b Zv.2 v ws'_� �'c'� <br /> mat- CC <br /> Inspection Form Included: Q vV <br /> Comments Included: <br /> B . ess R p's Sikna#jpfe I Phone umber Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS O ACK orrec - In orrect: � W EXAMPLE l 2 3 <br /> ■ Whiteopy:CaIR f <br /> ycle V Yellow Copy:Operator Pink Copy:LEA ® ■ <br />