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Waste Tire Su. ,iey & Inspection Report inspection Report Number <br /> C81Rec cle State of California - 1229955 <br /> Y CalRecycle 181(Rev.1000) Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � - Q 1 Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: G_q h ��� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> MLT -3 1 - � C) I MAS U <br /> Physical Address <br /> C <br /> Gs253 Inspection Date 4 1 ut <br /> Time In Time Out <br /> Business Rep Title 1 0 AM 11 �J O AM <br /> L ' S C> 0 PM l ,*PM <br /> lo� ' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ty (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _I 0 Active 0 Passenger Generator Outdoor 6 <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 40 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / Ffl <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ ` z <br /> Comments n_ \ `_ ,� ••hSp��i�0� �.�.�_� dh �--5 Qy� y <br /> yC C�f 95 opt <br /> Inspection Form Included: 0 <br /> Comments Included: !�✓� `(�� <br /> Business Rep's Signat Phone Number nspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />