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Waste Tire sfy & Inspection Repoection Report Number <br /> Cdecyd, State of California 1 - 1176648 <br /> CalRecycle 181(Rev. (Cal 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- I 5 ( 7' 5- 2 _ O I Inspection Type(Fill one) <br /> Site Suffix: T ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� ,;y� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> r-r-0yJ , (uc_bC t �vtC• j <br /> Physical Address II - l <br /> o 3� `ywr-14tArN Pa /�Gvvwccc <br /> Inspection Date Q -Z / U 3 <br /> Coq > <br /> �, ` 3 Time In Time Out <br /> Bus ess Rep Titl O AM t1 Q AM <br /> Gti I Rcdri ��,cr, aZ v ® PM 7 ® PM <br /> - <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 /> y� ® Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) N/A <br /> Q New Tire Dealer Q Auto Repair Q 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 ® 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 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 EX ) 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 /> w <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 in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> X 41 <br /> Inspection Form Included: Q !�/ j/�/��,/�.,�^ <br /> Comments Included: ! ^ mak IC-ASCI (ZO�jJ y(��— Qra <br /> Business Rep's Signet re2 Phone Number Inspector's Signature - Phone Number <br /> loll <br /> INSTRUCTIONS ON BACK Correct:0' Incorrect: E X A P�jRf 1112N 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink CE/ <br /> py:L <br />