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Waste Tire ,y & Inspection Repor spection Report Number ■ <br /> CalRecycle State of California 11 - 1. 17 6 4 3 5 <br /> CalRecycle 181(Rev. (Ca] 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- I 3 ) 8 © j Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection 0 Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y. ayi�cv� , 0 CHP Q CalRecycle Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address 3 <br /> y30y <br /> Inspection Date V / CJ <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> 0 PM PM <br /> - J - - 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 /> 3 3 • Active 0 Passenger ® Generator 0 Outdoor <br /> -_ O <br /> GPS Latitude 0 Closed 0 Altered O Hauler • Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> -- - --- --- - -- - ®Notice Of Violation 0 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 0 PRC§42956-Registration/Decal in Vehicle <br /> ® 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datemov <br /> / mz ,) <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> O Other:§ ----=- --_—_— <br /> Comments -,/� <br /> K.a'+t.buC, o'cG��')'`- <br /> Inspection Form Included: O x <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature hone Number <br /> INSTRUCTIONS ON BACK [Correct'0 Incorrect: (� ( E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink opy: <br />