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Waste Tire purvey & Inspection Reps. It Inspection Report Number ■ <br /> Cal Recycle State of cleCalifornia81 I a/ y 1 - 11765A 1 1 7 6 5 „ `') <br /> CalRecycle 181 Rev.y(CalRecycle) Survey <br /> Survey 1=o rm - Page 1 1 �' � <br /> Dept.of Resources Recycling and Recovery(CalRecycle) ,J <br /> Part A - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 � - r� I Inspection Type(Fill one) <br /> Site Suffix: 1 LJ e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1.1, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ` Q l Rn ES uh <br /> Inspection Date � / ® `7 / l , <br /> �� S Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> (r� <br /> 4 O PM � � � V % PM <br /> -- — - �+- - -- — - Operational Status Tire Type Business Role Storage Type <br /> / <br /> Tire Count (Whole/PTE) � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � l.0 <br /> S Active A Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply)If <br /> New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 /> 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 ® 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 o <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 /> Q Q Other:§ —_ <br /> Comments <br /> - <br /> 1 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signa Phone Number Inspe or's Signature ne Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy; © 0 <br />