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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177964 <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: - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ( � If Referral,choose referral type(Fill one) <br /> Identifier: q n J �Cl��1 UriQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �� ����� Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ` :)- 15 ® PM QPM <br /> - <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ` ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O Shredder ® 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O O Other:§ z <br /> Comments yl �.; �, �a�G �1�c, 1,��Q!1`�.0�0> /f111�h;G��C• G�(� �� <br /> s <br /> Inspection Form Included: 0 ��� C'I"�N�-�\^'V�pgg� <br /> Comments Included: [ �0—J <br /> 2BusqineRep's Signature Phone Number Insp Wr's Signature Phone Number <br /> - — 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: jEjXjAjM1 , L; E 1 2 ❑3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L A ® ■ <br />