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Inspection Report Number <br /> Waste Tire survey & Inspection RepuirlState of <br /> CalRecycle Ca Recyclelifornia 181(Rev.10/io) 1 I 1 - 1a 7 F 3 9 <br /> Dept.of Resources Recycling and Recovery(calRecycle) Survey Form Page <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 "` -l - O ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC r—' If Referral,choose referral type(Fill one) <br /> Identifier: J O(t Gt U1 r� (UN't 1 �1_ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address en e�ro b <br /> Inspection Date / � 5 / ( I <br /> Time In / Time Out <br /> Business Rep Title C ® AM / 6AM <br /> (� '• I ,(� I S Q PM j , V O PM <br /> + Operational Status Tire Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active Q Passenger � Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned O 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 Q Car Dealer Q Collection Q Crumb Rubber I• <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> V� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 m / m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or E <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — <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:§ z <br /> Comments <br /> Inspection Form Included: Q v ) h <br /> Comments Included: ® f I <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co © ■ <br /> ■ <br />