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Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle State of California f� 11 — 125594. 5 <br /> CalRecycle 181(Rev.yHO) Survey Form — Page `� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey® �7 �!�J Page <br /> Part A- Survey BLUE OR R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 ` „ � Q� LTJ -� � _ f1' ( Inspection Type(Fill one) <br /> Site Suffix: l �(/ ,J / �} I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalQ,,�, If Referral,choose referral type(Fill one) <br /> Identifier: �rL ,l�� 1� l.h n C`'t:-c.LLi 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ✓ - l � ,1 � (a` ) <br /> Ste; Tari- a�- �,rP s A4 - -- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title // , O AM / O AM <br /> V <br /> 2— � e PM � `/ � a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f/"/ <br /> � *Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered n//a1_1 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> p 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ID Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ffl m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 1010 1 Other:§ <br /> z <br /> Comments <br /> )o V i d l ct z- <br /> Inspection Form Included: 0, <br /> ia FIA I fyA - _4P':X1 <br /> Comments Included: ®� ' <br /> Business p's Signature hone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct. 30 Incorrect: g EXAMPLE 1 2 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />