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Waste Tire Spey & Inspection Repor_ ^inspection Report: Number ■ <br /> CalRecycle State of California 11 - 1176727 <br /> CalRecycle 181(Rev.y(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- r q rt Inspection Type(Fill one) <br /> 5- <br /> Site Suffix: 1 6j G p� 6 0 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local �� �� If Referral,choose referral type(Fill one) <br /> Identifier: A� ] -,L-( O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date / 1 - / L '7 <br /> �Vvc, 6A e?SJOtJ Time In Time Out G� <br /> Business Rep Title O AM O AM <br /> Ci ® PM 3 a ®i 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 Q Outdoor( <br /> O Q Closed Q Altered IV1 + <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - Q Planned ® OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <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 O 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> i <br /> Comments <br /> C � N <br /> Inspection Form Included: O <br /> Comments Included: ' 6 <br /> Business Rep' Signa ure o mber n cto Si ature Phone Number <br /> 40, 1 1 INSTRUCTIONS ON BACK Correct:0 Incorrect: XA �J E X A M P E 1 1213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:JEA ® . <br />