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Waste Tire SL vey & Inspection Repor. • Inspection Report Number ■ <br /> Cal Recycle State of cle181(R I 1 - 1210555 <br /> CalRecycle 181(Rev.y H0) 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: 4 -1 1 - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �C�n �� /^ _ If Referral,choose referral type(Fill one) <br /> Identifier: L l•� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 9 <br /> Inspection Date c <br /> CIA q5),O:—) I, <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> iNe-G-, 0 l ( Z J O PM 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 ® Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> ��� 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 /> 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 EXE N <br /> r <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 <br /> in Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> `J <br /> Inspection Form Included: <br /> Comments Included: �� ��� 1' d�"`� <br /> Business Rep's Signature Phone Number 'Ap'948jes'sh nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E X M L EL,1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copp:1-9A." ® ■ <br />