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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 123018:4 <br /> CalRecycle 181(Rev. (Cal 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 C � � � � 1 Inspection Type(Fill one) <br /> V <br /> Site Suffix: J l I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCwt b G' r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> q v i Y� �p v�/ <br /> Business or Facility Name Inspected By Inspector <br /> %k` e0.ckS -Nv� Vevckv C • C1 _ 1 0 k /" l ' <br /> Physical Address L 1 �J <br /> �S 22 PLct�-;C 0-\J fZ <br /> S' C`J'\T �SO09 Inspection Date <br /> O v1 Time In Time Out I <br /> Business Rep TiJtll(e� 0 AM � 2 c 0 AM <br /> 0 PIA 0 PM <br /> Coe 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 /> 6Tire Count(Whole/PTE) <br /> Active 0 Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXn <br /> Q 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 /> Lu <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments pv�-+ lis <br /> � O <br /> Inspection Form Included: Q —' 47 7 ' ���_q�3Z <br /> Comments Included: / S <br /> Business ep's Ign ure Phone Number Inspe tor's Signature Phone Number <br /> ,-� <br /> INSTRUCTIONS ON BACK Correct:O Incorrect: X � 9( E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />