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02 Waste Tire SAvey & Inspection Report Inspection Report Number <br /> CalRecycle State California I1 - 1230186 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey___-____ -- <br /> Business Profile Inspection Details <br /> TPID- i ` 1 � � � � _ � ' Inspection Type(Fill one) <br /> Site Suffix: ` 1 . Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <�5Lh `�( v t h Ca V V.,, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ;ea, pv3 4-cz C7�, 0t - <br /> Physical Address <br /> Inspection Date <br /> Time In i Time Out J <br /> Business Rep Title O AM —2 O AM <br /> W I ' 5 D O PM v *PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �7 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L 40 Active 49 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer • 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 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 /> I*Notice Of Violation Q Extension <br /> Q Q <br /> 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / ��l / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Mo2, <br /> Fi I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <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 /> g <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 Q In Compliance-No Violations o <br /> 010 Other:§ <br /> Comments k p k` 1 S V VV\ �OYIe d1� l S <br /> V'Y�IMQ_ <br /> Inspection Form Included: <br /> Comments Included- <br /> W7 <br /> ncluded: <br /> Bu ' essep ignature Ph ne Number Inspecto s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: , we �]JEJX�A�MJPJLJEJ 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />