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Waste Tire Svey & Inspection Repo, Inspection Report dumber <br /> CalRecycle State of cleCalifornia81(R I 1 - 1226536 <br /> CalRecycle 181(Rev.y(`10) 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- Inspection 3 i Inspection Type(Fill one) <br /> Site Suffix: 1 I ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral choose referral <br /> c type(Fill one) <br /> Identifier: O Irl v� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ACC tQc�t'T.I�� cN4- <br /> Physical Address -39 - 1 0 <br /> 60£'W_T I 1 "N <br /> Inspection Date ) 0 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> /� <br /> 0 `` d © ® PM 0 3 ® PM <br /> --- - --- -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger ® Generator Q Outdoor <br /> _ - O <br /> Latitude Q Closed Q Altered <br /> Caps Latitude Hauler ® Indoor <br /> 0 Q Inactive ® 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 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 /> 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 l <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXTj <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days 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 /> 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 /> Q Q Other:§ <br /> Comments <br /> \'j C's 1 o� c CA - <br /> Inspection Form Included: Q X <br /> Comments Included: ® - eZOg) lit. V-QQ,2 <br /> Busine s Repi nature Phone Number Inspector's <br /> Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr Incorrect: /��j N l� E X A M 1 2 3 62081 <br /> i' -J <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />