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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California /qurvey Form m Page 1 11 - 1210577 <br /> CalRecycle 161(Rev.ycal <br /> Dept.of Resources Recycling and Recovery(CalRecycle) SV <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: <br /> 1 .5 S U 5- 5 a � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.h ,UG C��� C�VV � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I 't t (} <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM AM <br /> I l - l S O PM J QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) '�, <br /> 9 Active ® Passenger -*Generator Q Outdoor <br /> GPS Latitude Q Closed Q Altered Q Hauler ® 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 /> Q New Tire Dealer Q 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 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 EX7) N <br /> a <br /> 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q rLeR 7 � <br /> Comments Included: <br /> lei <br /> ��$"�! G <br /> Bu in ss Rep's ignature Phone Number sp t r' Si atqfe Phone Number <br /> INSTRUCTIONS ON BACK Cor ct:0 Incorrect: X E A M L 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L ® ■ <br />