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Waste Tire : -,iey & Inspection Repo. Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226-208 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) - <br /> �artA - Survev _- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j / _ O r Inspection Type(Fill one) <br /> Site Suffix: — 1 b - _ - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysA Kddre� <br /> S• Z-vcc.c r Ave <br /> 11 // Inspection Date ` ; / d / <br /> Time In Time Out <br /> Business Rep Title Q AM / <br /> Q C K r(�,� ` � . —3 0 ® PM - C / --O 0 � AM <br /> /dnCaY1. D -J 7' Gf�li'NCC,Q �T'. ® 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 /> ® Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> LongitudeQ Planned Q OTR- Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q Government Q Retreader <br /> Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet <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 -- — " --" --- — -- -- Q Notice Of Violation Q Extension <br /> 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 <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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: (01111 Y 615 � <br /> Business Rep's Signature V Phone Number spec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* incorrect: EXAMPLE 1 12 3( 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />