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0 Waste Tire Su. ✓ey & Inspection Report inspection Report Number <br /> cal Recycle State of California I 1 ® 1196638 <br /> CalRecycle 181(Rev.y(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- Inspection Type(Fill one) <br /> Site Suffix: 6 44 L1 8 7 O t • Routine Q Re-inspection Q Referral Q Observation <br /> LocalSa� Gck�v\,�'„ If Referral,choose referral type(Fill one) <br /> Identifier: v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> F1 d dr Co�n ►� 3 �l - L o t A P-, <br /> Physicalal Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleAM �f 2 O AM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active 0 Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude * Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q 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 Q 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 /> !�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 /> PRC§42956-Registration/Decal in Vehicle <br /> 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 <br /> Q In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> - z <br /> Comments <br /> rO <br /> Inspection Form Included: Q <br /> Comments Included: ® � X04Ph <br /> Business Rep's Signature Phone Number sp ctor's ig ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM L E 1 1213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />