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---- --- --------------­ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210567 <br /> CalRecycle 181(Rev.y(Cal Survey Form ® Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey� ® �% <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: "� l ti C. (2 l 00 Routine Q Re-inspection Q Referral Q Observation <br /> Local /` ��� Cevw If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business orFacility Name Inspected By Inspector <br /> `` <br /> Physical Address L U"4 <br /> ^�t� Inspection Date j <br /> Time In Time Out <br /> Business Rep Title AMa 8 AM <br /> ` V 5 QPM 1 1 0 Q OPM <br /> Sc>,�� V'��fG�NVr��. ��y✓ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � 6 J <br /> ® Active ® Passenger 0 Generator a Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O 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 /> Notice Of Violation 0 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 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 /> r <br /> v <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 O Referred/CalRecycle Enforcement <br /> ul <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> f <br /> t <br /> i <br /> R <br /> t <br /> S <br /> if <br /> M <br /> 14 CCR§18462-Manifest System Requirements or Tire Dealers or Waste Tire Generators <br /> Q Q in Compliance-No Violations o <br /> Q 1 Q 1 Other:§ _- <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® RO�` W1,26 <br /> Business Rep's Signa ure Phone Number pW'sqfanature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L15,j 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® 0 <br />