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Waste Tire S, y & Inspection Repo�pection Report Number <br /> Cdecycle State of California <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 11 - 1176638 <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I z 7 - I Inspection Type(Fill one) <br /> Site Suffix: 7 ®Routine Q Re-inspection 0 Referral Q Observation <br /> Local �` If Referral,choose referral type(Fill one) <br /> Identifier: C O CHP Q CalRecycle Q Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C'Xfi'(Y,,, c; V e L4' W�ce ( S <br /> Physical Address <br /> 7 <br /> Inspection Date <br /> Lod C8a � z�f O <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> L4O ® PM © ` � � ®PM <br /> C4 VY+IM t-� 7 �L11'i�l� �GU'✓tC:t�� v -- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> [ y <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> r pS Latitude <br /> O Q Closed Q Altered <br /> _MauterIndoor <br /> - <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 /> Notice Of Violation 0 Extension i <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateMlo <br /> / Fo <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 1,1 <br /> O 0. 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> ui <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators C In Compliance-No Violations o <br /> 10 0 Other:§ <br /> Comments <br /> V'C�6 <br /> Inspection Form Included: Q .LCi / ' r7l <br /> Comments Included: ® / . 2 z <br /> Busine Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct. incorrect: X �` VE X A M L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />