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Waste Tire Sup Bey & Inspection Repoli Inspection Report Number ■ <br /> CalRecycle State of California I 1 1242376 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- � � � _ Q � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: �ar J(z'aq V;y\ coVv\�%i Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cov. � s� <br /> e , r,c . 3 - o <br /> Physical Addresss <br /> 322 'C=, U-oe.�vv\o(e� SX. <br /> Inspection Date C) 'z / 2 1 / <br /> C� �1S 1 <br /> �o�v��•eCo� 33� Time In Time Out <br /> Business Rep Title *AM 1 ®AM <br /> O � � <br /> SO PM ` � � V O PM <br /> it-e�.,� �/1.� P '�c� �s�1:w�a�oc <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ` 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active ! Passenger Q Generator IIIII, Outdoor 6 <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ` Indoorq <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned 0 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 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q 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 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 •In Compliance-No Violations o <br /> Q Q 1 Other:§ <br /> CommentsV h"\'N�e Q'^ '�s'!��'�a`c la <br /> she, Wc�S •�S� S�e.0 <br /> �C) U�b�ciT�Oy�S 6i' P�C2QS ak��p�CeC� <br /> Inspection Form Included: Q <br /> Comments included: s Z —= /�L� 'w� <br /> Business Rep' Signa re Phone Number Inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: \/\ 70 <br /> (� EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />