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Waste Tire ley & Inspection Repo, Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226561 <br /> CalRecycle 181(Rev. (Cal 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 /> TPID- // - © r Inspection Type(Fill one) <br /> Site Suffix: d tv ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(, - � Lam_ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> Physical Address <br /> 130 j�t2T I 1J <br /> Inspection Date ) 0 / L L <br /> Time In Time Out <br /> Business Rep TitleO AM Q AM <br /> 0 1 LI S_ ® PM Q ( �S ®PM <br /> t f i c S 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 /> 30 ® Active Q Passenger ® Generator ® Outdoor <br /> G P$ Latitude 0 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use <br /> 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 /> - - - - --- - <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) N <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 <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q x <br /> Comments Included: <br /> Business Rep's Ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ',ON BACK Correct: Incorrect ( EXAMPLE11-1213162081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA <br />