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Waste Tire Sui Vey & Inspection Report ispection Report Number ■ <br /> cal Recycle State of California I 1 - 1196397 <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- Q 1 1 _ Q l Inspection Type(Fill one) <br /> Site Suffix: t "L jo Routine Q Re-inspection Q Referral Q Observation <br /> Localr �� If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Names <br /> Inspected By Inspector <br /> Q r U n-ka' s _��f e, ("'- aT r, Q <br /> Physical Address p l - Q O CS Cb TT 0 <br /> c A i <br /> /� Inspection Date / "Z I 3 <br /> 5�L10 J <br /> Time In Time Out <br /> Business Rep Title0 O AM O AM <br /> ® PM ' � � �PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 5 ! S Active ®Passenger (5 Generator 0 Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q 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 /> ( ,0 New Tire Dealer 9 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 Q Hauler Q Agriculture Q Shredder ® Other Taw <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments n t 1 A 4W A < <br /> No w rel a,Ti vnS (niTcA.0 us.- - C on o-m. <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> B iness Rep's Signatur Phone umber Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � E X A M P 1 2111 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CoRLV <br /> ® ■ <br />