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® 'a Waste Tire 11rvey & Inspection Repo, Inspection Report Number ■ <br /> cal Recycle State of California I 1 - 1226617 <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 <br /> 1 Inspection Type(Fill one) <br /> LA " <br /> Site Suffix: l ` 1 C J Q Routine Q Re-inspection Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: S a U 0(.j_ UN n C D tt r\ Q CHP Q CalRecycle Q Complaint Q Educational Visit II* Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L6'k w o Od� <br /> Physical Address C LDS <br /> Inspection Date / Z / <br /> Time In Time Out <br /> Business Rep Title O ® AM I j0 Q O AM <br /> 1 Q PM a PM <br /> -- — - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) „y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> /V') QActive Q Passenger Q Generator Q Outdoor <br /> - - - -_ - N J f'v;A �� <br /> O 0 Closed Q Altere <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q 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 Q 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 NIA <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 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 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 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 Q Other:§ <br /> I z <br /> Comments W s u rt. ? G <br /> LA�;�n: <br /> Inspection Form Included: Q � v p <br /> Comments Included: Q � - <br /> Business Rep's Signature Phone Number Ine o <br /> spr's Signaturej, Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ® � I EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />