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Waste Tire Survey & Inspection Repos . , Inspection Report Number <br /> CalRecycle State of California I 1 - 1226621 <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- I f� !, _ ire Inspection Type(Fill one) <br /> Site Suffix. �j �j ` Lf ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local1 / _ If Referral,choose referral type(Fill one) <br /> Identifier: Urn 70 CLI u) f'% (�(}��� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr4ss l CS a) 0 <br /> GA IS-n'0 Inspection Date <br /> Time In Time Out <br /> Business Rep Title 9 ' ) /-� 19 AM O FM <br /> P- "I lJ U <br /> < L5 r twy,LI? 5�t)Se m m CooC. QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S(J <br /> /, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / <br /> ® Active 0 Passenger ®Generator 0 Out000r <br /> D 0 Closed 0 Altered N 1A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® 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 /> OService Station O Hauler Agriculture O Shredder • Other <br /> r!n <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 0 Extension <br /> 0 O <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 /> 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 EXT) 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 /> E <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:§ 11 I 11 l^ <br /> Comments O.n I s �1 I�e [.t,il&C `R t a 1 ou, <br /> v\10S; R = <br /> 0 1 O a 17115 h S (A1WS <br /> concern, <br /> Inspection Form Included: Za9-565r6-(-Z)$ `� <br /> Comments Included: - — — 5 �� I — <br /> _ __• Bus e s Re 's Signature _ Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />