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Waste Tire Avey & Inspection Repor .. Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226319 <br /> CalRecycle 181(Rev. (clai Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey _ _BLUE OR BLACK_IN_K PEN <br /> Ins _ <br /> Business Profile pection Details <br /> TPID- C Inspection Type(Fill one) <br /> Site Suffix: J �p 3 3 <br /> ® Routine 0 Re inspection Q Referral Q Observation <br /> LocalC �� U �'1� �ott If Referral,choose referral type(Fill one) <br /> Identifier: J 0 CHP Q CalRecycle 0 Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Pf��c�� 3 C o <br /> Physical Address I ES J„ � <br /> 57 0 <br /> �u P C � (533 <br /> Inspection Date / /'`1 / <br /> ` � lJ <br /> Time In Time Out <br /> Business Rep Title d O AMQ AM <br /> PM � 3 � ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(V1/hole/PTE) t' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d 0 Active Q Passenger S Generator Outdoor <br /> O <br /> GPS Latitude O Closed Q Altered O Hauler 0 Indoor <br /> O O Inactive ,Truck <br /> Longitude - 0 Planned Q OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet O Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber l A <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder ® Other T Lt,ler mG1'�zl44e PWC1 <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 /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date IT / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7 N <br /> n <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 O Other:§ <br /> 1 <br /> Comments Q-014; 1�_ (J ' �. — <br /> o ow <br /> -- -- - - of <br /> Inspection Form�nc <br /> ncluded: ��G z <br /> Comments luded: ®--- LLI V'�' �Iv"I`� C J1n <br /> Business Reps Signature - Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect:. X A P 1 33 62081 <br /> E <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C py A <br />