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Waste Tire &.... ✓ey & Inspection Repoc Inspection Report Number . <br /> Cal Recycle State of California <br /> (Rev. <br /> R I 1 - 1210472 <br /> CalRecycle 181(Rev.y(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- ,^ q _ //1 Inspection Type(Fill one) <br /> U <br /> Site Suffix: t v ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SM, V 4 n `Or A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v Inspected By Inspector <br /> (Am nr\ bk o CIA <br /> Q vf�, _ 0 l CSCC��3"(7 <br /> Physical ddress <br /> Inspection Date <br /> ; Time In Time Out <br /> Business Rep Title l AM 0 AM <br /> ` 0 PM a ®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 0 Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered rj 1_11A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned # OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) CtA(t <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 1 Other:§ 1 <br /> Comments . VA 4 I n UW 1 S <br /> - <br /> ND- <br /> Vl <br /> Inspection Form Included: 01 - p <br /> Comments Included: ® _N2 x/ 20 <br /> Busine4s hep s Signatu a Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: E X IA P JEJ 1112131 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co <br /> .LEA ® 0 <br />