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Waste Tire Su. iey & Inspection Report nspection Report Ne mbar <br /> CalRecycle State of California 11 m 1210270 <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_ U 1 Inspection Type(Fill one) <br /> Site Suffix: , —1 ✓ d 2 — O 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: TO CLI V' e\ - %.5A- 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> gel �_' : o wp-sk 9 ` 't v <br /> Physical Address <br /> ���� C a5 20� Inspection Date � / 0 <br /> Skd <br /> Time In Time Out <br /> Business Rep Title �\\ AM 1 -3 g AM <br /> V QPM I I QPM <br /> 0_c w z e l�a�d'C's C' F.0 <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 /> 7 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> i <br /> GpS Latitude o0 Closed 0 Altered <br /> Q Hauler 0 Indoor <br /> 0 0 Inactive *Truck <br /> Longitude — 0 Planned 40 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 /> 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 I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <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 <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 EXl) 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 /> Lu <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:§ <br /> Comments <br /> N3O \)�b to- ( S C�t CRS _. CC"NA t-C, 'A <br /> Inspection Form Included: p Lt� <br /> Comments Included: �/ c� 6 <br /> usi ss Rep's Signature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ACK Correct: Incorrect: EXAMPLE'_1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />