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Waste Tire F fey & Inspection Repor Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226543 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey -__ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> 1 TPID- Inspection Type(Fill one) <br /> Site Suffix: Lj C) G 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local c If Referral,choose referral type(Fill one) <br /> Identifier: JGVYI ` tom, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ti Inspected By Inspector <br /> Physical Address - C? �p -�I'r <br /> i rwv <br /> r �c�Ly - LFi vl� �� - - - - - - <br /> Inspection Date L 0 � 7— -3 � � I <br /> �► -� <br /> pt�v.- <br /> C s <br /> � L-� 4 Z 3� Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> n 0 a ® PM � �' C� d ® PM <br /> ---- Operational Status Tire Type Business Role to <br /> Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> Latitude <br /> GPS i Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container I <br /> Business Type(Fill all that apply) /\J/ <br /> Q New Tire Dealer Q Auto Repair 0 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 /> 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 /> 0 I Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 10 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 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 /> (Re <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days quired for NOV or EXT) N <br /> r <br /> v <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers l Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 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 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Bus" s Rep's Signature Phone Number nspector's Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. E X A M P I L I El I 1 2 N 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />