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Waste Tire Su. Jey & Inspection Reporpinspection Report Number <br /> CalRecycle State of California I 1 - 1255758 <br /> (Cal <br /> CalRecycle 181(Rev.f Survey Form - Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � /'�, � � � � „ ( Inspection Type(Fill one) <br /> Site Suffix: `"[ �j 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: /Y7/V�y C ( 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> I <br /> � Inspected By Inspector <br /> Physical Address y 3-14 - I <br /> Inspection Date 1 l l <br /> (J Time In Time Out <br /> Business Rep Tale 22 �, O AM O AM <br /> � i h-e-- <br /> A _a • 0 1 O,PM 3 ' S � a PM <br /> �!',4 Sim-I� <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 0 Paa s�enger 0 Generator 0 Outdoor <br /> Latitude 0 ® Closed 0 Altered n <br /> G 0 Hauler 0 Indoor <br /> o Q Inactive Q Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement g <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 1 O Other:§ <br /> z <br /> Comments wawb tis l <br /> -� Tb t( t v� t k)ao ryi Z ,' ko vi/M2, c_4 �r;.� ay a <br /> jd'I� <br /> CGyI.�'Q r h <br /> o I I al OCC z an-.d Gi r <br /> Inspection Form Included: 0 R �(Q <br /> Comments Included: -- <br /> Business to <br /> p's Signatu Phone Number Inspecr's Signa ure hone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />