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Waste Tire 91&ey & Inspection Repoi Inspection Report Number <br /> State of California <br /> CalRecycle I 1 -1176579 <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 /> TPID- - ( Inspection Type(Fill one) <br /> I <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local If <br /> If Referral,choose referral type(Fill one) <br /> Identifier: �jC.vY� U -J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CA walk-, <br /> Physical Address <br /> rr Fes- <br /> t 0(v S <br /> Inspection Date <br /> �-ocl �+ Cl S?_y0 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I 2 3 s PM ® PM <br /> 1 C — --- — - - -- -- -- <br /> Om--' o/k Nmjuam 1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �7 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4P 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 ® 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 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 <br /> Q 1 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 EXE <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 u, <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 1',�,rr�� S <br /> �r3�.t�In 14,L_ i r1 S)'X IN CAI J C.� 41-, - QJnCJ -1w e _ <br /> Y1a�cG.L <br /> Inspection Form Included: Q <br /> Comments Included: <br /> -- -- <br /> _ uslness ep'sSignature Phone TTu_mIJ_er --lnspe�s Signature Phone umber_ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink py: A <br />