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Waste Tire Sr.,vey & Inspection Repor ,, Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245082 <br /> CalRecycle 181(Rev. (Cal 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- >t /, lj Q Inspection Type(Fill one) <br /> Site Suffix: `f "T `t *Routine Q Re-inspection Q Referral Q Observation <br /> Local n _ If Referral,choose referral type(Fill one) <br /> Identifier: !-_�o yrD�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> l V I,.C{ F&Y GQ <br /> PhysiciAddress - ' C) <br /> *32-li�Z &ao r Crc_L <br /> Inspection Date <br /> Time In Time Out <br /> Buusi1nes's,Rep Title 0 AM �f �.� �--- 0 AM <br /> 0 PM v V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �c (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active i Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor-};ra <br /> O - <br /> Q Inactive Q Truck <br /> `- <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 /> 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 /> 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 Q Other:§ _ <br /> i <br /> Comments coyn <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspe isSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle I Yellow Copy:Operator Pink Copy:LEA <br />