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Waste Tire S... ✓ey & Inspection Reporm :spection Report Number <br /> State of California <br /> CalRecycle 11 - 1255800 <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- 1 D 37- <br /> 3 /� Inspection Type(Fill one) <br /> Site Suffix: / -/ V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: /� ��j (7 I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> r Inspected By Inspector <br /> I -.�It.f�, <br /> Physical Address U > 1 ( & W 90� <br /> Inspection Date V "z— / <br /> Time In Time Out <br /> Business Rep �f,,, Title <br /> j /) •7 0 AM L •- h 0 AM <br /> J�Sih t F� Vis I r.(1r31 Cka `-f' C. ® PM G U ® 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 /> 0� ® Active Q Passenger 4D Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler Q indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned OTR 0 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 a Other _TVCtaw <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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E?C7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> M <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 /> 11 z <br /> Comments P"&^ kLx U_;Uo !• k /4 ��f�'' 42C2Z <br /> l 1� <br /> Inspection Form Included: Q <br /> Comments Included: • C& - <br /> Busines p's Signature Phone Number Inspector's igna u hone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />