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Waste Tire Arvey & Ins ection Re orp Inspection Report Number <br /> CalRecycleState of California _ — <br /> Caycling le 181(Rev.y(Cal Survey Form Page 1 11 1244946 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `7 � c � _ © � Inspection Type(Fill one) <br /> Site Suffix: 1 nv S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCA��pu�kAt� C(OtA � Q CHP Q CalRecycleQ Complaint Q Educational Visit Q Other <br /> Business or Facility Name AI <br /> Inspected By Inspector <br /> I( knS S O'y�t1Le Oi cs. _ <br /> Physical Address rT W'TT b <br /> 1 WS Inspection Date , / ZL I I^ <br /> Time In Time Out 4� <br /> Business Rep Title 0 0 AM O 0 AM <br /> ( <br /> ` (A^ �Q�[11 0Zll�fler ® PM Q ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �U e Active Q Passenger ® Generator I* Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 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 <br /> 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 <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 /> 1010 Other:§ <br /> Comments w W`S -k <br /> C.r n <br /> Inspection Form Included: Q M 1XAI0, AaAbAA�t-317 1 <br /> + <br /> Comments Included: is 1 `1 <br /> Business Rep's Signature Phone Number Inspe t is Signature Ohone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: X � E X A M P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />