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03 Waste Tire Su. ,iey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1210547 <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- �7 l,�1 Inspection Type(Fill one) <br /> Site Suffix: 1 / 0 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> -- - ` <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address \ S I e C� <br /> 3c)� S - ?e c IM c�✓� �0 <br /> Inspection Date Q / 2 2- <br /> Time <br /> Time In Time Out <br /> Business Rep Title 4 V : 1"1` O O PM Q Q 0 PM <br /> e pec O`er -� <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 Outdo/or <br /> 0 ® Closed Q Altered IA N lor <br /> e <br /> GPS Latitude /Vl� P N1.A 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 /> Q New Tire Dealer Q Auto Repair Q 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 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 /> Q Q - �Notice Of Violation Q Extension <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 /> 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) 2 <br /> a <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 1 Q 1 Other:§ <br /> Comments <br /> �✓�CJ� � - �`���� W Q-S�� �/� V�_��0�-�d�� AC �Ch.S �� l euc+ot <br /> n, <br /> Inspection Form Included: Q <br /> Comments Included: Q ' <br /> 0 2 � ��ctg3� <br /> y <br /> Business Rep' ignature Phone Number Inspe tor's ignature Phone Number <br /> INSTRUCTIONS ON BACK [&rect:0 Incorrect: X � qJ EXAMPLE 1 2 3 62081 <br /> MWhite Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />