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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California 11 - 1176396 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surma _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� 'S � ] � Inspection Type(Fill one) <br /> Site Suffix: CN 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Faciitty Name V Inspected By Inspector <br /> Physical Address ( Q J &n ES r,( D <br /> Inspection Date / 5 1 I <br /> C)\Ytk 5�5 1 (9� � <br /> Time In Time Out <br /> Business� Rep (� Title/ l rI O AM O O AM 1(�At- � l X1VJ) <br /> 1 p I-CJ- 9 PM � � ® PM <br /> pV Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' I f Active a Passenger ® Generator I* Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use i Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 40 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 /> Q Q - ®Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> ® 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 Mb / M� 5 U , <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 EXE N <br /> a <br /> 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 /> Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ 1 1 1 <br /> Commentstj 1 Al <br /> Inspection Form Included: Q / <br /> -T2 �In <br /> pe <br /> Comments Included: -- --- _ -_ - — - <br /> Business s Signature Phone Number pe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre t: 1 orrect: ( E X A M P L E 1 2 Q <br /> ■ White Copy:Ca ec Yellow Copy:Operator Pink Copy:LEA © ■ <br />