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Waste Tire SIiey & Inspection Reporfalnspection Report Number <br /> CalRecycle State of California I 1 - 1229985 <br /> CalRecycle 181(Rev.ry y(Ca(CalRSurvey Form - Page 1 <br /> Dept.of Resources Recycling and Recoveecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �} � � � _ Inspection Type(Fill one) <br /> Site Suffix: L1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /` Grk4y-A—z <br /> If Referral,choose referral type(Fill one) <br /> Identifier: `� �l�n�ry V;� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Nameyyyy��--��`''IIInspected By Inspector <br /> Physical Address kA <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title p ^` 19 AM I 0 AM <br /> Q PM L .0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0_ <br /> :(Fill.one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v <br /> *.Active , Passenger * Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 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 /> 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 0 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX>) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 0 <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 Other:§ <br /> Comments VOL) i V1� �3� � \ S C7'� �,� �J✓� ' �_�Z <br /> C� <br /> IL t <br /> �(9�c9, PY—L GC cc)w <br /> Inspection Form Included: 0 ��,/ <br /> G a rJ <br /> Comments Included: <br /> usi s p's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: � E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />