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Waste Tire Sevey & Inspection Report. , Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1255812 <br /> CalRecycle 181(Rev. (Cal 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- I !,� 7 _ Inspection Type(Fill one) <br /> Site Suffix: , L' r,;J 0 I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r �1 L)is Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �^ � Inspected By Inspector <br /> Physical Address <br /> ^ ��� Inspection Date <br /> L��� -� Cl Time In Time Out <br /> Business Rep Title 0 AMr� ] AM <br /> � ✓ I I • 2 3 O PM I L l S PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' [ 40 Active 10 Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned 0 OTR O 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 Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 O 1 Other:§ <br /> Comments <br /> .o <br /> V l_Do <br /> Inspection Form Included: Q <br /> Comments Included: 0 �� �� <br /> Business Rep's S" ature Phone Number Inspector's Si ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />