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Waste Tire Survey & Inspection Repon Inspection Report Nurnber <br /> CalRecycle State of cle 181nia ]_1 - 117 6 4 5 4 <br /> CalRecycle 181(Rev.y(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- r ^ y q _ © Inspection Type(Fill one) <br /> Site Suffix: 1p e! oC 1 e Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: J oeaq u n CoLl, ll, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> C A 2.0S <br /> Time In Time Out <br /> Business Rep Title ( ! ® AM u AM <br /> Q�(�1 U WAC V O PM I I 1 Q PM <br /> 1` O-(� \fit <br /> 13 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 /> 0 Active 0 Passenger 0 Generator 0 OutAoor <br /> /� <br /> - O * Closed 0 Altered N/4 /A <br /> GPS Latitude /A 0 Hauler 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXn N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments ; s IJ S <br /> T <br /> N� y; 1 OM om." b a o� 0Aoafn. <br /> Inspection Form Included: 0 1 <br /> Comments Included:® I 'a� �ll <br /> j Business Rep's Signature Phone Number Inspec 's Signature Pone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M L E 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® ■ <br />