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Waste Tire Stey & Inspection RepoAslnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245083 <br /> CalRecycle 181(Rev.y(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- I Z 1 f Inspection Type(Fill one) <br /> Site Suffix: �1 f 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: ' S� (,��Y-\ �G.(R,V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 5voc_IV-toy_\ _Qf'j 0-0.k 0 i <br /> Physical Address W I <br /> �- % Cs?i�{� Thr► -- ' ` <br /> `� <br /> Inspection Date -4- / Z v <br /> S�I Z <br /> Time In Time Out <br /> Business Rep Titlei 0 AM 2 ii 0 AM <br /> I 0 PM ® PM <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 ® Passenger ® Generator ® Outdoor <br /> O <br /> GP$ Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ® 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 <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <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 /> Comments ISA I rvu?��►lN' C9_Yt <br /> �l ovj i v .-J C""o nLLQ c)- e <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: _ � EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />