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Waste Tire Su. vey & Inspection Reporpinspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177988 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q I / m O Inspection Type(Fill one) <br /> Site Suffix: <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local < a� ��u If Referral,choose referral type(Fill one) <br /> Identifier: J �J (/�1 n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �K,� kc\ - 1 I <br /> Physical Address \ < <br /> 3 2�1�I <br /> 64") <br /> de-Inspection Date r7 <br /> Time In Time Out <br /> Business Rep Title O d 0 AM h 0 AM <br /> is PM V 4 PM <br /> - <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) >� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active i Passenger 0 Generator Q Outdoor <br /> o Q Closed Q Altered <br /> ��� Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 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 <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) N <br /> a <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 /> 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 Q1 Other:§ <br /> � •`�.� ll •• __ `� �, J z <br /> Comments 1�1� lA�(A -Ail` 1 n�ev�iof� 01"}1 U� fY115( �� CWNlA� <br /> 1 U\(AVS _oT cbflcevn <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number 41nspejcr'SSignatre Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: >� E X A M P L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ■ <br />