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Waste Tire S... rey & Inspection Reporil. Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210503 <br /> CalRecycle 181(Rev. (Cal 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- � � A 1 1 14 _ � � Inspection Type(Fill one) <br /> Site Suffix: `� �1 o e Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: (� ��1� &k() Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cuo�_ ��o S Sa. Sir <br /> Physical Address ' ES(oTT 0 <br /> Inspection Date <br /> v Time In Time Out <br /> Business Rep Title I ^� 16 AM /l <br /> AM <br /> 2 V <br /> Q PM <br /> 1- �PM <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ,e Active ® Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR Q End-Use a Container <br /> Business Type(Fill all that apply) <br /> 40 New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> to 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 <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 <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) N <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 /> 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 1 Q 1 Other:§ <br /> Comments ' z <br /> 1 !1VQ1A <br /> S nL`- <br /> �,� _«IUAS QF COn cvn. <br /> Inspection Form Included: ® i <br /> Comments Included: <br /> Business Rep s Signatu a Phone Number nsignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ® ■ <br />