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03 Waste Tire Joey & Inspection RepdO'nspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226313 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l O T J Iy I i 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 ) CoIf Referral,choose referral type(Fill one) <br /> Identifier: S�l�1 J p u�, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> QK7) (,a. LU, <br /> Physical Address <br /> Inspection Date �j <br /> C �� rime In Time Out J �- <br /> Business Rep Title F O AM � PM <br /> r 0 AM <br /> 5 5 <br /> A PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � Q <br /> ®Active ® Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 1b OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) wt <br /> 0 New Tire Dealer 0 Auto Repair ®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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 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 EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years In <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <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 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments T!, i n azn CX1 S (�((,TI'G taw D(A, �4c 01-A)I r) <br /> orl <br /> 4 Vi(AA0_- % US to[c as V� r�csn ce rr� <br /> Inspection Form Included: �— <br /> Comments Included: - <br /> Business Rep's Signat Phone Number Insp Signature Phone Number <br /> c or's <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ZX W <br /> E X I A I M L 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop © ■ <br />