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■ rite Tire Stet & Inl specNon Repo if Inspection Report Number ■ <br /> Cel Recyde State of California 11 1245358 <br /> @� u e CalRecycle 181(Rev.y(Ca[ Survey Form - Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) _ BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- I � ,�- e C�T,� ) Inspection Type(Fill one) <br /> Site Suffix: & Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: , �3Ln 3baquir, dcu, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> HT1 T)0"b� - I <br /> Physical Address p(� <br /> `3coSo mak) oy, <br /> Inspection Date �( / / 1JF__ <br /> Time In Time Out <br /> Business Rep Title j 011 ` a 0 AM <br /> J.✓C�-r'1 ,��LIS r YQ^ ��� l Q ® PM t Z� ®'PM <br /> 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 /> 0 Active Q Passenger ® Generator Q Outdoor <br /> o Q Closed Q Altered-' <br /> GpS Latitude Q Hauler Q Indoor <br /> o Q Inactive 4DTruck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �Vm�� <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 <br /> 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 EXT) <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments � ,,,�C�1'1.�� Lt�G21L-� � + � „„Q ,,. •17-, <br /> i�ytp� G�eo�— low�� VJC0 a(o-L&1- <br /> Inspection Form Included: Q <br /> Comments Included: <br /> uCMegsM MOWign Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK �orrect:* �Incorrect: � EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />