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Waste Tire Sd%ey & Inspection Repor einspection Report Number <br /> CalRecycle State of California 11 - 1245290 <br /> CalRecycle 181(Rev.y(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- � � � � � � � � ` Inspection Type(Fill one) <br /> -7Site Suffix: 1 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �G Vti� C �� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name c Inspected By Inspector ` \ <br /> Physical Address i/ lj O 1 M � 1 v <br /> CA -I�V'J-z Inspection Date O V � 2 6 � 1 -5 <br /> Time In v Time Out <br /> Business Rep Title <br /> A ,,,,`- - ` O AM I 0 AM <br /> �T ©C`C\� /" Y�0.Y��� 1 �� I PM +QPM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 7 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 9 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive . Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Q� <br /> 0 New Tire Dealer 0 Auto Repair 0 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 • 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 /> 0 0 PR - 0 Notice Of Violation 0 Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / F11 <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 EXn N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 1 Other:§ t <br /> Comments <br /> wa'S rr •� <br /> mer V\ <br /> Inspection Form Included: 0 � 'Lo7�3� <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />