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r <br /> 02 Waste Tire Survey & Inspection Report 'Inspection Report Number <br /> CalRecycle State of California I 1 - 1210253 <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- —1 Inspection Type(Fill one) <br /> Site Suffix: ' Q CL C © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r` If Referral,choose referral type(Fill one) <br /> Identifier: `'\ ��r' �"� L 't'�4 <br /> `�7 � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 4C �VL1Ti�k� Ad Address �✓V✓ CCL✓ �+ <br /> Inspection Date <br /> fA ql;W_' Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' Z ­7 ®PM cJ 0 7 61)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 /> m Active ® Passenger ® Generator 48 Outdoor <br /> O Q Closed Q Altered <br /> GPS 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 ® 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 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 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m m N <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 EXTJ 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 /> 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 o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> i <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business e s Signature Phone Number ins6q(W06 Wnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � 7w E X A E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop .L <br />