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Waste Tirb Survey & Inspection Re��rt Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1255701 <br /> CalRecycle 181(Rev. (Ca[ 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- 01 I i r` Inspection Type(Fill one) <br /> Site Suffix: "[ ( V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� y(� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 0 Inspected By Inspector <br /> T-e—rr i I 1 iYa tits pow, cy) e _ <br /> Physical Address <br /> 2-4" P ct,�Pbs, RzJ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I 0 AM J [�_ �J O AM <br /> ( ® PM ( / ( �PM <br /> (lean Leal � Sh � 1�� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ?!�h)e/PTE) <br /> �� ' 9 Active Q Passenger 6 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair *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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 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 ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 0 <br /> 0 <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators40 In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsU�e e i-bt�. 'I w2!)0 c r 0 Gly—�I.u� <br /> , <br /> �Q <br /> Inspection Form Included: Q <br /> Comments Included: 0Z <br /> Business Rep's Signature Phone Number AInspctor's Sigrow Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 07q] E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />