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Waste Tire SL_ _ey & Inspection Report :spection Report Number <br /> State of California <br /> CalRecycle 11 -1176597 <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- Inspection_ O ' Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �, If Referral,choose referral type(Fill one) <br /> Identifier: ca,1 --ac{ct y. (� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 0 - --- -- - - <br /> Inspected By Inspector <br /> Physical Address <br /> 1 _f i I- <br /> Inspection Date C) l / <br /> stoc.IC}Or CA /G S 20 <br /> Time In Time Out <br /> Business Rep Title O AM0 AM <br /> O G ® PM iZ �? ® PM <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 /> ®Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude , Q Hauler ®-indoor �. <br /> O <br /> Q Inactive ® Truck i <br /> Longitude - Q Planned ® 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 /> ----- —I Q Notice Of Violation Q Extension <br /> Q Q 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 EXE <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance-No Violations / <br /> Q 1Q Other:§ <br /> _ <br /> Comments <br /> r 4-k ey 746k4_ <br /> Inspection Form Included: Q <br /> Comments Included: 2CJ t k 625 -04 Z <br /> 3 <br /> - - -- Busine s Rep's Signature Phone Number - -Inspector's-Signature - - —Phrone-Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E 123 62081 <br /> �� �� <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y:L <br />