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Waste Tire ; vey & Inspection Repo Inspection Report Number ■ <br /> CalRecycle State of California 11 -1176573 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.or Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I j S - I Inspection Type(Fill one) <br /> { <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: gal", Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1-1 Inspected By Inspector <br /> eciC4-', (�-'c Sp�C_ cs u7he . 3 <br /> Physical Address <br /> Inspection Date C) & / Q / 1 <br /> LidzyC <br /> Time In Time Out <br /> Business Rep Title ® t l ( O AM 0 AM <br /> / b ® PM d 1 ® 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 Q Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ® Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) N/A <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other PkXC ;Lr, vviC4,vu„(�xC• <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> IV 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 I <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> E <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities a, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q 1 Q 1 Other:§ '. <br /> Comments 1 � � /► �(� <br /> �n7lJln� t YlC r sr a 4w:r 4'Lt l S C.(/4 J:A G.AM� `-}'fix a "t-O •r � ,� <br /> W U C <br /> Inspection Form Included: Q <br /> Comments Included. ® AM &7==' ezo.9 L't 3 <br /> Business ep's gnature Phone Number —Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect: ? E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink tv <br />