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Waste Tire Su. .ey & Inspection Report inspection Report dumber <br /> cle State of California <br /> CalRecycle CalRecycle 161(Rev.10/10) Survey Form - Page 1 I 1 1196476 <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� - � � Inspection Type(Fill one) <br /> Site Suffix: J * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �O—Y\ �dO�G %?Ity-� �Ay 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name/' Own \ ep y <br /> Inspected B Inspector <br /> Physical Address d <br /> 5 'kp� C <br /> 2�0 Inspection Date ' / o S / I 3 <br /> Time In Time Out C <br /> Business Rep Title 1AM AM <br /> 'U s 0 O PM , F J Q PM <br /> Operational Status Tire Type Business Role Storage TYP® <br /> Tire Count (Whole/PTE) %6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger 0 Generator 0 Ou�door <br /> O 0 Closed 0 Altered /j Pt <br /> GPS Latitude 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 /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder .10 Other �1�o�2�ex�2. `c�o� 9vi 1•�v��`�-� <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 Notice Of Violation 0 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 /> 0 0 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 <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 /> Lu <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 1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> i Comments Included: <br /> J r � � <br /> Busines Re S <br /> Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:40 Incorrect: � � q� E X A M P' L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />