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■ 02 Waste Tore Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 12 4 2 2 5 3 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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 Type(Fill one) <br /> Site Suffix: 2j d 5 a Routine Q Re-inspection Q Referral Q Observation <br /> LocalCC A_ L If Referral,choose referral type(Fill one) <br /> Identifier. SOS', �� Com,UVL Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JJJJJ Inspected By Inspector <br /> Physical Address Q ( 4 Ki' M4!S(JLA <br /> Inspection Date <br /> ` <br /> Time In Time Out <br /> Business Rep Title 1 0 AM _ 0 AM <br /> PM ® PM <br /> CycL�� l,Jr� �,I-- wl�t,,vl,lt►�L <br /> 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 /> 0 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q End-Use Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 I 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 /> 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ z <br /> Comments <br /> Inspection Form Included: Q -717 q <br /> d -y�8 t6 <br /> Comments Included: ® <br /> Busln s Rep's Signature Phone Numder Ins a or' i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct:* Incorrect: g E X A L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink o :L ® ■ <br />