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Waste Tire Su. .ey & Inspection Report nispection Report Number <br /> CalRecycle State of California( I 1 - 121014 6 <br /> CalRecycle 181(Rev.y(CalRecycle) <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- 4 Q If <br /> nspection Type(Fill one) <br /> Site Suffix: ` �j 6 t� 0 ' Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: aq,vZr C ��k`t O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 7 Inspected By Inspector <br /> Physical Address <br /> �pC70 - - <br /> ����` Inspection Date Q / 06 1 3 <br /> S �1ti� b Time In V Time Out <br /> Business Rep Title `` O AM 0 AM <br /> C>gRe "t\U ' 0 PM O 0 PM <br /> '^aOperational 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 /> 0 Active Q Passenger • Generator Q Outdoor <br /> O Q Closed O Altered <br /> G PS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Truck <br /> Longitude - 0 Planned OTR 0 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Othere ` <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O 0 § - �Notice Of Violation � Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / M <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �In Compliance-No Violations o <br /> O O Other: <br /> Comments �V • r� ���-'�i� ���.c-� ���fLG�,�i `�-�n�,0�_�� ���� <br /> t` v�cQC <br /> Inspection Form Included: O <br /> Comments Included: <br /> usiness ReA Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: Xa;l V 11 EXAM P.JLJEJ 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />