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■ Waste Tire Survey & Inspection Report - Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1176774 <br /> CalRecycle 181(Rev. Ho) 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- _ O I Inspection Type(Fill one) <br /> Site Suffix: l "� ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �I r �a��kl n (01� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> �^ y Inspected By Inspector <br /> Physical Address 1 3 1 I 0 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I O AM r� j 0 AM <br /> ® PM ,v^( ® 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 /> '10 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered /V�q <br /> G�� Latitude a A 0 Hauler ° 0 Indoof ' <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I /A <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators It In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments CA\ I„ 0 11 N <br /> `Lo r`R— <br /> i 1�1 Ul5 nOkeA� I <br /> C (UnUfn- <br /> Nc71� P) A431nc53 u5 ��U�2 c7v>7 �S [ ion. C c7 SS- <br /> Inspection <br /> tInspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7 9 E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />