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0 Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210400 <br /> CalRecycle 181(Rev. (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- ( O / �j O Inspection Type(Fill one) <br /> Site Suffix: 1 S p `6 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50-y` V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I ! Inspected By Inspector <br /> �hcYvLct.\ S\T� "�! �l - (, � L � AT FV <br /> Physical Address d <br /> - <br /> Inspection Date S / L L 3 <br /> ��Gti�� C SZo6 <br /> Time In Time Out <br /> Business Rep Title 4 + , O 0 AM Z Q 0 AM <br /> XC �� I `� QPM ® PM <br /> I,eO 2 e-S ICO�v►4 11�tstw"\ • <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered A)/A <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) 1a�. <br /> Q New Tire Dealer Q Auto Repair *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 A 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 /> Notice Of Violation Q Extension <br /> Q Q 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date® / FC / ' 3 <br /> 9 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 EXE N <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 /> LU <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 /> Q 1 Q 1 Other:§ <br /> Comments \-e-- T-C C yme c2la �� <br /> Ala <br /> Inspection Form Include. � � Ga3� trO�� <br /> Comments Inclu, ed: J Q 1 <br /> IBu n s Rep's Signature Phone Number . Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON ACK Correct: Incorrect: ® �__]jE X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />