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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196618 <br /> CalRecycle 161(Rev. (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- Inspection Type(Fill one) <br /> Site Suffix: ( g e 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \ �� f„ If Referral,choose referral type(Fill one) <br /> Identifier: C)Cl� `w'V 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address A✓;i <br /> /d��✓l� ».�d�2i,( acv� �✓' �T� � <br /> Inspection Date 1 n ® 1 <br /> V'�G vL �. Cf( GTS331 1 O� <br /> Time In Time Out <br /> Business Rep Title ®AM ? Q AM <br /> cc � �,�,,, L � Lit 7QPM L � J � BPM <br /> �Gt1M �Ct(�GL/ �""�'' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ® Active ® Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 /> Q Notice Of Violation Q 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 M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ip In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments ` <br /> Inspection Form Included: `/�✓" <br /> Comments Included: <br /> Business Rep's Signat re Phone Number s ct Si nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct' Incorrect: � E A VI L I E 1 2131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />