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® Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 <br /> CalRecycle 161(Rev. y(Cal S Irvey Form <br /> A 11 gage 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey M! Y�i�"J 1245064 <br /> Part A-Survey _-_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� _� � � � Inspection Type(Fill one) <br /> Site Suffix: [ )�I_ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: co ryu Iy 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name � Inspected By Inspector <br /> c �DaY r) Chev ral e+ m. <br /> Physical Address <br /> Inspection Date / 0 / ' <br /> -(S a--7(_/ <br /> Time In Time Out <br /> Business RepTiittllee / O AM L�11� O AM <br /> //�� <br /> Q Y✓ l� 14is �/l of iC -►� l/ 7 0 PM ` o PM <br /> —� U Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <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 /> 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 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> _ _ a <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 /> 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 V-Oy 1 i Ylou 7 4e, `t yLR_, �{�t�•,n,• L;OY1 f d1�SL <br /> �jo �J�a� cs�r OF <br /> Inspection Form Included: 01, <br /> Comments Included: <br /> usiness ep's Signature Phone Number Inspect is re Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: X � NJ E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ®' ■ <br />