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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle 181(R 11 - 1177527 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Fora ® 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- r Q 1 , _ r^ Inspection Type(Fill one) <br /> Site Suffix: J L "l Q, lJ , ® Routine Q Re-inspection Q Refenal Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 CO Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business'or^Facility Name Inspected By Inspector <br /> Physical Address <br /> (A Inspection Date 2) <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> • U ® PM S PM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O N <br /> ® Closed Q Altered /,� pj,/ <br /> GPS Latitude N Q Hauler Q Indoor <br /> O Q Inactive Q Truck/ <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Truckirig 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 OIA <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 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / FF / m N <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 EXT) n <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q 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 /> Q Q Other:§ <br /> z <br /> CommentsQV%A: N,1 w� I� I u N <br /> 1�.7 cA S »n _A[01Ab�'�� �� <br /> (3 s: i 7Lvvt is cn.,) nc. Uvis'At 6n 5i c- C 1bk TP4, <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X*NJ E X A P E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y:L ® ■ <br />