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Waste Tire SG. vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1177696. <br /> CalRecycle 181(Rev. (Cal Survey Fora - Page l <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j Inspection Type(Fill one) <br /> Site Suffix: 1 © 5 _ 0 0 Routine ® Re-inspection 0 Referral 0 Observation <br /> Local �9 \�� If Referral,choose referral type(Fill one) <br /> Identifier: c•ih �' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical A Mss l G t "J le_,_ <br /> qL6 nI, <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM 1 10 AM <br /> C & ' Z_ 0 0 PM Z 3 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 /> 0 Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude �Hauler 4& Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR End-Use 0 Container <br /> Business Type(Fill all that apply) <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <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 /> O 1 O 1 Other:§ <br /> z <br /> Comments LL <br /> �S N <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number 1 s o tat re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: EIXIAIMIPIKEI1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ky <br /> ® 0 <br />