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® Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br /> Cal Recycle State of California I 1 1196628 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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- 1Inspection Type(Fill one) <br /> Site Suffix: , 6 L1 0( • Routine Q Re-inspection Q Referral Q Observation <br /> LocalSf�✓1. O v'� COJ If Referral,choose referral type(Fill one) <br /> Identifier: �� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> \�\ rn-\ &—)Ll 3 - o IL <br /> Physical Address A r l Aq Q u L/� <br /> Inspection Date <br /> rt e.-cc C X5336 l <br /> Time In Time Out <br /> Business Rep Title AM ® AM <br /> Ct : O C) O PM � 0 0 O QPM <br /> --- — Operational Status Tire Type Business Role Storage Type. <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ' • Active 4j Passenger Q Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler O Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR O End-Use 0 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 O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 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 /> O O - Q Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> _ _ a <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 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 /> z <br /> Comments <br /> S p <br /> Inspection Form Included: Q <br /> Comments Included: f. �- Z <br /> usine s Rep's Signature Phone Number In e s ig ature Phone Number <br /> 62081 <br /> INSTRUCTIO S ON BACK Correct:* Incorrect: X �FEJXAM L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />