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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle — <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 I1 1196358 <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: Routine Q Re-inspection Q Referral Q Observation <br /> LocalS t If Referral,choose referral type(Fill one) <br /> Identifier: (.�c1 U I/�,1'\ 1 {� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� I l- Inspected By Inspector <br /> k r " '.A o so`G�►'ler S ( O 1 ' <br /> Physical Address - <br /> Inspection Date 5— / 0 3 / <br /> m(0.ulv CA S <br /> Time In Time Out <br /> Business Rep Title ` • AM `I v #AM <br /> c { I oPM I QPM <br /> Pum, T �nLi ��f101' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> o Active Q Passenger ®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® 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 ® 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 /> 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 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 N <br /> Ir <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 o <br /> Q Q Other(:§ <br /> Comments oval r\0 � WL►SJ�. � fC� �� b� ��. O ���1-� rl'�� <br /> -W"0— �kol))_W ' n s MN__ <br /> N v; <br /> 01� 0 5 c_IC!I-A,4- <br /> Inspection Form Included: Q " A <br /> Comments Included:® b 3 5 ao <br /> Business Rep's Signature Phone Number Inspe to 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( E X A M L 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: © ■ <br />