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Y t <br /> Waste Tire Sup vey & Inspection Repor. Inspection Report Number <br /> CalRecycle State of California I 1 - 1177675 <br /> CalRecycle 181(Rev. (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- Inspection Type(Fill one) <br /> Site Suffix: _T! Jt"� 9- G ® Routine Q Re-inspection Q Referral O Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: S1 �t �� L�l/N�� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> Physical Address - <br /> Inspection Date <br /> CA•� q'5 �(� Time In Time Out <br /> Business Rep Title (V AM ®AM <br /> Z Q PM 1 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> T (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> &Active ® Passenger Generator Q Outdoor <br /> P$ <br /> Latitude O O Closed O Altered 1/ A <br /> CiQ Hauler Q Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer I* Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m M / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 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 <br /> Inspection Form Included: Q ` Q•`7 6 , <br /> 0 3 OD <br /> Comments Included: /�J <br /> Bus Hess Rep's Signature Phone Number Ins ec or's S' n ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: g EXAP, L E 12 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink 4y:L <br />