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■ A Waste Tire y & Inspection Repo4opection Report Number ■ <br /> CalRecycle State of California I 1 - 1176731 <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� � Q � � _ O � Inspection Type(Fill one) <br /> Site Suffix: D * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. CO CHP O CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> I t Yc cq �c''1n►I�� / <br /> Physical Address 3 <br /> 'u. S , <br /> Inspection Date <br /> �d; C�� 9s�YO <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> a / ' © 0 ® PM v d ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ' O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O 7 ® Active is Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> -_ rpQ Latitude Q Hauler- Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O 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 /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O 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 Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle M / FFI / M <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q Q 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 O Referred/CalRecycle Enforcement <br /> O O 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 /> Q O Other:§ <br /> Comments <br /> p juste i r( 6&42(,, �� ILGf Jrxa <br /> Inspection Form Included: Q /� <br /> Comments Included: ® ess p 4,���r�Z <br /> Bus Rep's Signature Phone Number ` Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: \/ � E X A L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co A <br />