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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev. (CO) Survey Form - I1 1242462 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i p O - O Inspection Type(Fill one) <br /> Site Suffix: l L *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: S Ck n O w l U111 S1l 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addrdds (7� <br /> S ( CA Inspection Date <br /> Time In Time Out I <br /> Business Rep Title M /) 0 AM 0 ® AM <br /> V !`(1R S GCrVJA1 l �'Cx cl I v S C) 0 PM ( v 5 Q PM <br /> U �� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Vj <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive I* Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) LoaA- <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 &,kjl -uy&(rq1.,.tv <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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 m / M / m <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 EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 Other:§ 1 <br /> Comments <br /> (Z'3y�n¢.,`, Z � ,f cy (tet-;�� vn � Xw. o•� �Y1� k �. <br /> � Q uS ncitqA <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � E X A M P E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />