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Waste Tire Survey & Inspection Report, Inspection Report Number ■ <br /> CalRecycle State of cle 181nia 11 - 1226622 <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- ,,ttom� I Inspection Type(Fill one) <br /> Site Suffix: ' V 3 �/ I le Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� J(��,/ I , ^ Cp�(� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name w I Vl Inspected By Inspector <br /> Physical Address J <br /> �l 5 5 S G , c)1 <br /> Inspection Date 1 / 5 / I <br /> A �Sao� 1 <br /> Time In Time Out <br /> Business Rep Title 2 Q AM �j O AM <br /> J a * PM ® PM <br /> �� c Uic� SU�� Opv�k;uns rn c. <br /> -- - - -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r Q (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �0 Q ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Altered <br /> i GPS Latitude Q Hauler 41 Indoor <br /> o Q Inactive � Truck <br /> Longitude - Q Planned OTR End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> * Used Tire Dealer Q Auto Body Q Car Dealer IS Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture ® Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- - - -- 3 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 p( �11 _ )(A`&_ ) t_ I SncJila­� ( hJ 1 Wf`(1QlJ on tlh1 J7 (AM <br /> - <br /> S� <br /> Inspection Form Included: <br /> Comments Included: ® , �/ O <br /> Bu ness Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W EXAMPLE 1 2 3 62091 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />