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Waste Tire S". vey & Inspection Repor,. Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1177876 <br /> CalRecycle 181(Rev.y(Ca[ 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- Inspection( e Q ' Inspection Type(Fill one) <br /> Site Suffix: I tt l!1 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(A{\ JDa y IAI Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \\J, <br /> C_ 04`e <br /> Inspect By- Q Inspector <br /> Physical Address Ill 3 <br /> CA SZ �s Inspection Date <br /> J Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM • PM <br /> Operational Status Tire Type Business Role Storage Type <br /> y <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l� <br /> ® Active Q Passenger ® Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 • 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 Notice Of Violation Q Extension <br /> Q Q <br /> 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 Ex7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments .A-h"— w� 1 f 11n i 7S 1_ _ <br /> ^ _ ►�U <br /> �U , <br /> Inspection Form Included: Q ` <br /> 9-931- -- )72 <br /> Comments Included:� - <br /> Business Rep's Signature Phone Number Inspec s Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:O Incorrect: EXAM L E! 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink op : ® ■ <br />