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Waste Tire Su. iey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196519 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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� 1 � � � - � � Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: jO_Y\ �'�n v�� ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 'r�1 l� Inspected By Inspector <br /> Physical Address F a - <br /> Inspection Date � � � 2, / 1 <br /> LaA1r\co CJS <br /> Time In Time Out <br /> Business Rep Title i, /� I 0 AM n 0 AM <br /> � <br /> (t' l 5 O PM L S a PM <br /> � <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active Q Passenger 0 Generator Q OuNoo <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that a_;Dry) <br /> Q New Tire Dealer Q Auto Repair Q Trucking FleetQ Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q A,.to 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 ENFORCEME\\NT 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 <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 EJC N <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 /> W <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 /> Comments rc�_ \_ _\ ' 1 �� <br /> &NCc- <br /> N v'- rra��es�S c �� eC <br /> Inspection Form Included: Q �/� <br /> Comments Included: 4usi �R p's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON B Correct:0 Incorrect: E�XJA�Mj PILIE1 I 1 12N 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />