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Waste Tire Su, Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 1210256 <br /> CalRecycle 181(Rev. (Ca] 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- Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r>G( �l If Referral,choose referral type(Fill one) <br /> Identifier: ) V✓�. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !!! Inspected By Inspector <br /> fA L� <br /> Physical Address <br /> Inspection Date / `Z' / <br /> Lw�1 v CA �S Time In Time Out <br /> Business Rep Title ® AM AM <br /> i;"((t( l 0 ' S & Q PM t ( E) O PM <br /> V_ 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 /> Q Active Q Passenger ® Generator Q Outpoor <br /> O ® Closed Q Alter d f//T <br /> Cid$ Latitude ;d/A Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 I& Other U tyIC �.- <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 <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 <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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> u, <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 /> 6 <br /> Comments <br /> Inspection Form Included: J <br /> Comments Included: <br /> Business ature Phone Number lnst&hAignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A L E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink y: ® ■ <br />