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Waste Tire e & Inspection Re VI " Inspection Report Number ■ <br /> CalRecycle y P _ Rep <br /> State of Califo1(R I 1 - 117672- 2 <br /> CalRecycle 181 Survey Form Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- / 0vt Inspection Type(Fill one) <br /> Site Suffix: 0 lJ - / J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -� / If Referral,choose referral type(Fill one) <br /> Identifier: �(�(1 J Q �� C( a � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> - - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 0 <br /> �� Time In <br /> aI `J Time Out <br /> Business Rep Title r� 0 * AM S 0 AM <br /> O PM <br /> 'l J Q�)j)".r I V v I O PM <br /> 1��L <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> Tire Count (Whole/PTE) `Jj <br /> 18 Active 0 Passenger 0 Generator O Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 6 Truck <br /> Longitude - 0 Planned 0 OTR End Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 6 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 ® Other I(ukv� �u ?11 �nrA— <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STA—TUBS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 m / m / m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments V_01A\ 1 I�j-,, S'�k. N <br /> wD6 rl(� t <br /> Inspection Form Included: 0 _ <br /> 7c_-7i <br /> Comments Included: <br /> Bu ' gnature Phone Number Insp or's Signature Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS BACK Correct:• Incorrect: � NJ E X A M P E 1 2 3 <br /> ■ ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E © <br />