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Waste Tire y & Inspection Repor3pection Report Number <br /> Cal Recycle State of California 11 - 11- 176628 <br /> CalRecycle 181(Rev. (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- _ U / Inspection Type(Fill one) <br /> Site Suffix: S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �, O CHP Q CalRecycle Q Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical ddress <br /> lolls S . G -rope LL <br /> Inspection Date 0 -6 b/ l / <br /> Cf� lls�yG` <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> 1 / .3 o O PM aZ tJ U ® PM <br /> N/ A - -- - <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 /> Q Active O Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> Caps Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) /VYA N/A- N/A <br /> It . 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 ® 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 /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension <br /> Q § 9 P I <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O 0 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 ®In Compliance-No Violations o <br /> Other:§ ----- <br /> Comments <br /> Inspection Form Included: 0� �O4L <br /> Comments Included: <br /> Business Rep's Signature Phone Number 'Inspector' .Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Nl E X A Pj L JK 11 1723 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CUT <br />