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Waste Tire Arvey & Ins ection Re or0inspection Report Number <br /> CalRecycle Inspection <br /> p _ <br /> State of California I 1 1255824 <br /> CalRecycle 181{Rev.10110) <br /> 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- I I Inspection Type(Fill one) <br /> O _ <br /> Site Suffix: 0 a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: fbi._n Ca� O CHP Q CalRecycle Q Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> V Inspection Date � 1 / � � / <br /> �try-\ / /ISl d�p Time In Time Out <br /> Business Rep Title I 7b AM t ' � r AM <br /> QPM ( QPM <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 /> or 4VActive • Passenger 6 Generator 0 Outdoor <br /> or <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned • OTR O 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 Q Hauler Q Agriculture Q Shredder • 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 Q 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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 010 1 Other:§ <br /> Comments _' _NIJ�---�a -4�o <br /> CJI-u .,, <br /> '41" _ <br /> QD t11-0 /I <br /> Inspection Form Included: 0 <br /> 4cm <br /> C 2 C <br /> Comments Included: � <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � EXAM P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop .LE <br />