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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle 181(R 11 - 1177742 <br /> CalRecycle 161(Rev.y(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- o Inspection Type(Fill one) <br /> Site Suffix: I 6 Q r ® Routine 0 Re-inspection Q Referral Q Observation <br /> LocalC _ If Referral,choose referral type(Fill one) <br /> Identifier:_—_JG�N— _fil - Q-CHIS-Q CalRecycle 0 Complaint—Q-Educational-Visit-O-Other- <br /> Busin'ess or Facility Name v ((( Inspected By Inspector <br /> Physical A 1 (�ZS J7✓I�LI� i 'V <br /> ddress <br /> 9-� lu C ham:u'hec- L>2 <br /> Inspection Date <br /> `" t) Time In Time Out <br /> Business Rep Title ® AM jj ®AM <br /> / C) S 0 P l ! 0PM <br /> f'rCl✓l J i IC1Y►'3'S Ci�.t✓!l�.� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger Generator ® Outdoor <br /> o O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive Q Truck <br /> Longitude - O Planned O OTR a End-Use O Container <br /> Business Type(Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body .O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder 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 O Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required far NOV or EXE <br /> ® O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ - u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> O O Other:§ <br /> - - z <br /> Comments ` <br /> `y V <br /> Inspection Form Included: 46 <br /> Comments Included: ® 2ef1 'Z2� <br /> il'u7iness Rep's Signature Phone Number I c r' gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 11 E X A M P I l E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />