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Waste Tire S6. ,fey & Inspection ftport Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1255833 <br /> CalRecycle 181(Rev. (Ca[ Survey Fora Page Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 1 6 5 2 o V ! 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �® Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address -2, <br /> 20�bp <br /> Inspection Date 0 2 / 02- <br /> Time <br /> 2- <br /> Time In Time Out <br /> Business Rep \_ Title AM AM <br /> �^ 0 PM ' 1 � � O PM <br /> Mac r2.Z &c neco„� -tve wG - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger 0 Generator 0 Outdoor 3 <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler 0 Indoor Z 3 <br /> O Q Inactive 0 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 0 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 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exf7 <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 1 Q 1 Other:§ <br /> Comments t. <br /> 01 <br /> Inspection Form Included: Q <br /> Comments Included: s^ Z y <br /> usiness Rep's Signature Phone Number Inspecto s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M L 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />