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02 Waste Tire Sulrvey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of cleCalifornia81 <br /> I 1 1 -1176735 <br /> CalRecycle 181 Rev.y(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- q /� Inspection Type(Fill one) <br /> Site Suffix: LA 3 I $ lJ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC_� If Referral,choose referral type(Fill one) <br /> Identifier: sc-r, JC7a LAI r\ �n�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address 3 I o <br /> M9s33 Inspection Date LA / � � � I <br /> "U(� ec. &, ('R Time In Time Out <br /> Business Rep Title U 0 AM r 0 AM <br /> {'- PM J PM <br /> t',� Operational Status Tire Type Business Role Storage Type <br /> ,.y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) r((J <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered lV/1 <br /> GPS Latitude � Hauler 0 Indoor <br /> O 0 Inactive • Truck <br /> Longitude – 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair • 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 <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 0 Notice Of Violation 0 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 /> M / m / m <br /> 0 * 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 /> 2 <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 0 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: 0 C,709 CR 301� —�-� <br /> Comments Included: <br /> x935 )(" �c�� ��q 31 <br /> business Rep's Signature Phone Number Inspecto Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:4 Incorrect: X g E X A M P E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink ColkL © ■ <br />