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Waste Tire S ey & Inspection Repor Inspection Report Number <br /> CalRecycle state of California 11 - 1177838 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Fora - 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- G Inspection Type(Fill one) <br /> Site Suffix: 3 1 ® I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �—' i If Referral,choose referral type(Fill one) <br /> Identifier: { J ��r1 �/��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> C a- A ' <br /> Physical Address 3 � - � 0 <br /> Inspection Date 1 a S( / 13 <br /> ����� Time In Time Out <br /> Business Rep Title O Q 0 AM 0 AM <br /> Nh Ud1 (- a".�I v r/" o w c r L is PM (a PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a (f) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> *Active ® Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer • 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Datem m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 9 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <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 g <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 <br /> in Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> (� z <br /> Comments <br /> Inspection Form Included: Q G�'�'✓ v <br /> Comments Included: ' - - <br /> r's S <br /> Business Rep's Signat hone errIns ctoignature hone Number <br /> INSTRUCTIONS ON BACK Correct:0 In o rect: EXAM 1 2 3 62081 ■ <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink p <br />