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Waste Tire SL- -1y & Inspection Report nspection Report Number <br /> ealRecycle State of California 11 - 1186148 <br /> CalRecycle 181(Rev.10Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Recycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> -- — -- ...---- .- -I - <br /> TPID- / i Inspection Type(Fill one) <br /> Site Suffix: i � of / ( (» j # Routine O Re-inspection O Referral O Observation <br /> Local { If Referral,choose referral type(Fill one) <br /> Identifier: 1 Q CHP O CalRecycle O Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> t Inspected By Inspector <br /> i t <br /> Physical Address <br /> ��` Inspection Date <br /> &A �3 lCJ / <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> i <br /> � L� QPMQPM <br /> i,.✓•r i e%1 i�? L'_,-' •...�`'£Alr:?. 4. ) '• • re �Lt�-e.�(,f)aC)/ i _._... �__ _ <br /> -- -- -- -- - T � ---- 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 /> Q Active O Passenger Q Generator Q Outdoor <br /> GPS Latitude ( Closed Q Altered O Hauler Q Indoor <br /> . i l .... _... 0 Q Inactive Q Truck <br /> i [ <br /> Longitude - i {V End-Use Container <br /> 9 Q Planned <br /> OTR <br /> Business Type(Fill all that apply) <br /> Q Nf--"""New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O 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 Notice Of Violation O Extension <br /> O O 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 <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / m <br /> Q Q 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) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Lf) Compliance-No Violations <br /> O LQ Other:§ -- -- _ <br /> Comments <br /> lul Z 0 7 _, g <br /> arZIPk, t <br /> A <br /> Inspection Form Included. Q "" � / t'" <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />