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Waste Tire Su, ✓ey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1230231 <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- O � Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local { If Referral,choose referral type(Fill one) <br /> Identifier: �OQA U �av�ei...� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _1 Inspected By Inspector <br /> `ll - 1 0 l RA7 1 V <br /> Physical Address <br /> � Inspection Date ' � / =� O / <br /> K 1 Time In Time Out <br /> Business Rep Titley J`� O AM O AM <br /> �1.51'�'t�� I 4 v 0 PM ' � C) 0 PM <br /> C Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 9 Generator ! Outdoor 17 <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C Q Inactive ! Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 Containerz <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 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 EXE N <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 is In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> v� ew 5 <br /> Inspection Form Included: Q AA <br /> Comments Included:49 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �J EXAM E 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />