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Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226231 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Q � � � � � _ � I Inspection Type(Fill one) <br /> Site Suffix: I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: J /)GI G) 11) C �,�" Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �_ GG Inspected By Inspector <br /> 71 c(L, S Vl O� _ D <br /> Physical Address /1 1 '�� l u►cl�t 1 <br /> Inspection Date <br /> b Time In Time Outo <br /> Business Rep TitleJ_ � ` 0 AM � 0 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ` <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 Q 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 Notice Of Violation Q 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 <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 Q Other:§ <br /> Commentsra=6 /A���� <br /> �Jr� <br /> 0 s _Aft_G� >7� � cltsn. <br /> Inspection Form Included: Q <br /> Comments Included: ---Wim' _ _ --��`-- - -- -- <br /> Bu ness s ign urePhone Num er Inspect s Signature P ne Number <br /> - ---- ---- - 62081 <br /> INSTRUCTIONS ON BACK Cor :e Incorrect: l >� E I X I A M L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co LE ■ <br />