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Waste Tire 6&ey & Inspection Repo Inspection Report Number <br /> State of California T <br /> CalRecycle — 7 6 8 u 5 <br /> CalRecycle 181(Rev. (Ca[ Survey Fora p age 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TP)D- J Inspection Type(Fill one) <br /> Site Suffix: Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: � � C t v/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t <br /> JJ Inspected By Inspector <br /> Physical Address lot <br /> Inspection DateLR tj� <br /> CA <br /> Time In Time Out <br /> Business Rep Title �T l ® AM �AM <br /> (6� 1 L1 LU �-L� ��GL L CQt/1� files , O PM 0 C9_ O 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 /> -b- I* Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered X14 ''11 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned • 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 C� S L I CJ 1 1 f s <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 Date m m / 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 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 /> z <br /> Comments <br /> Inspection Form Included. Q K rlti5 <br /> _ `Z15 7-3 Included <br /> Business Rep's Signature Phone Number (n or+"S gn ure - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: E X A M L'E 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />