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Waste Tire "E vey & Inspection Repo. Inspection Report Number ■ <br /> cal Recycle State of California I 1 - 1176712 <br /> CalRecycle 181(Rev. (CalRecycle) <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- Inspection Type(Fill one) <br /> Site Suffix: —7 <br /> I 6 c2 —7 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local \^ �� -A I If Referral,choose referral type(Fill one) <br /> Identifier: �� ✓l,L t-E v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ci - O t 14 <br /> Physical Address / <br /> a05C)C:) ��-oiA Or , <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep �II Title ®AM 40 AM <br /> E . / 0 . 3 o O PM l d O PM <br /> — vv 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 /> ' ® Active Q Passenger IIs Generator ® Outdoor <br /> O <br /> -lawn. - Latitude Q Closed Q Altered Q kaawer <br /> O Q Inactive III&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 ® 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 FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- Q Notice Of Violation Q Extension <br /> Q Q 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 / m / 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 EXT) N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> 10 1 Q 1Other:§ <br /> Comments <br /> Inspection Form Included: Qjoaw&7 <br /> �- <br /> Comments Included: ® - - �� <br /> Business Rep's Signature Phone Number nrse ' I n ure Phone Number <br /> INSTRUCTIONS ON BACK 'Correct Incorrect: E X A L E 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copk4_1_* <br />