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Waste Tire Slur vey & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of cle181California 11 - 1245042 <br /> CalRecycle 181(Rev.y(Cal Survey Fora G Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � D �A � a � _ O � Inspection Type(Fill one) <br /> Site Suffix: - I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� ( b�� �h 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business <br /> ororjFacility Name Inspected By Inspector \ <br /> PhPhysicalAdd1 e sC�� �\C�� CA - l 0 l M T \1) <br /> aS n Inspection Date <br /> " Lb� Time In v Time Out I <br /> Business Rep Title 0AAM 2 O AM <br /> lJ ® PM Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 7 . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _1 O O L <br /> •Active . Passenger 40 Generator .Outdoor <br /> O 0 Closed 0 Altered <br /> ��� Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive * Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 0 Q Notice Of Violation 0 Extension <br /> 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 7 <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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 /> W <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 0 Other:§ <br /> Comments•-r _\ `�^`�_ _�` ��C � _\ <br /> J� <br /> Inspection Form Included: * F <br /> Comments Inclu d: <br /> 'Business Rep's Signature Phone Number nspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACKrrect:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> Co <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />