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Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196662 <br /> CalRecycle 181(Rev.y(Co) 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 Inspection Type(Fill one) <br /> Site Suffix: 1 `1 "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1TGq,n—1 V`� CO 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `" Inspected By Inspector <br /> 3 o� _ O 1 /�1 ��C T U <br /> 31 <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ( � 40AM 1 O AM <br /> Q PM 1 40 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whol /PTE O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger IV Generator- 10 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> 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 <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 /> 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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> �ceaS c&- <br /> Inspection Form Included. Q Z <br /> tf—$3Lc7 <br /> Comments Included: 0 <br /> Bus' ss 's Aignture Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BA Corr ' Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ hite Copy:C scycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />