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Waste Tire Sui Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California81( II - 123022-0 <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- O O - Q Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 36 a/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name x''11 Inspected By Inspector <br /> De- <br /> Physical Address <br /> CA Inspection Date I z / ' ) Z <br /> � ` ��� SLIT Time In Time Out <br /> Business Rep �^ Title i O AM O AM <br /> L e Jb 6w�c 1 0 PM t PM <br /> D Operational Status Tire Type I Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 0 Active Q Passenger .Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q HauWw Q Indoor <br /> Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-0%e Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dsmantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q f�loUce Of Viogbon Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deedbne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateM / '171 <br /> I I / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 111 III III <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exr� N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 /> z <br /> Comments �7 1 <br /> w a-� i-ir-e <br /> Q v\- v�C <br /> Inspection Form Included: QI ,.� eq <br /> � <br /> Comments Included: <br /> Bus'w�ess Rep's&galure 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 />