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Waste Tire SAiey & Inspection Repo inspection Report Number <br /> CalRecycle State of California 1 1 1255741 <br /> CalRecycle 181(Rev. (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- 1 ��j `2 _ Inspection Type(Fill one) <br /> Site Suffix: ( z! l J f Is Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J0C�,_q l; Vj �. ,�(L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V` Inspected B Inspector <br /> �i TI-Q, <br /> Y P t <br /> Physical Address <br /> tetf Inspection Date / Z C <br /> (/ Time In Time Out <br /> Business Rep Title ® AM 0 AM <br /> a I ' 2- 1 Q PM I "'� l.- a PM <br /> I 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 /> ' ' I ,o Active * Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 /> 40 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 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 m / m / m <br /> Q Q 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 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 Q Other:§ <br /> Comments V���, 1A_) ., A„ CXk i 612 <br /> Y`JO U �cel ri B1 Ln.QJ CN /1�if n� ��C��.rr� <br /> Inspection Form Included: Q <br /> Comments Included: I& (-f- naso /9G�G,��, (7Oz 3! 13—9y 73 <br /> Business Rep's Signature Phone Number Inspec is Sign Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: � J� g EXAMPLE 11123 162081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />