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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1210125 <br /> CalRecycle 181(Rev. (Cal Survey Form - Wage 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- a (� Q Inspection Type(Fill one) <br /> Site Suffix: 1 1 b "l D d 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> �.� �b coq � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> F2 i g 7-1 - 1 0 1 fiTQ <br /> Physical Address c <br /> \ �� <br /> Inspection Date <8 3 <br /> Time In Time Out 1 <br /> Business Rep Title AM r\ * AM <br /> 0 PM � v Z � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol PTEZ Q Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' l� 0 Active 00 Passenger OP Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q-Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 40 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ _ <br /> Comments ` <br /> Inspection Form Included: QA'? <br /> // � —/ /� �U�'�� <br /> � Comments Included: <br /> 4. wo�:iZc0- � <br /> usiness Rep's Signature Phone Number Inspe tor's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I EIXIAIMI PILIE1 1112 3 R 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />