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Inspection Re Inspection Report Number <br /> Waste Tire ey & Inspec p � <br /> CalRecycle State of California I 1 -1176831 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � t 1 � _ Q � Inspection Type(Fill one) <br /> `7 � <br /> Site Suffix: l� Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �4M 13 4>taf�Lkt r) Chun Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _�"11 Inspected By Inspector <br /> � u\ _Ts u-vlti A c L<ss�f I C's - 1 <br /> Physical Addre 3 1 <br /> - <br /> (C�� �1 C ^ 1,S-a1z Inspection Date / r l J <br /> J1L�fJ p� ,{ "� <br /> Time In Time Out <br /> Business Rep Title � r� 0 AM 0 AM <br /> `Jw ��' <br /> DS Q Q PM ` o PM <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 /> A Active V Passenger • Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler e Indoor <br /> O Q Inactive e Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ( New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 40 Other { .r <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 Q § - �Notice Of Violation Q Extension <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® / IC61 / <br /> M11`1 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 /> 2 <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ 1 /� <br /> Comments Vtr )i oUS i nS��c tl0^ l - b '1k n oxic- OJl <br /> Inspection Form Included: Q <br /> Comments Includ <br /> Busin s re Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTI BACK [Correct: Incorrect: EXAMI 1 I2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop6L � <br /> ■ <br />