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Waste Tire SuR vey & Inspection RepcA Inspection Report Number ■ <br /> CalRecycle State of California q _ n <br /> CalRecycle 161(Rev.y(Cal Survey Form Il - Page 1 1242197 <br /> Dept of Resources Recycling and Recovery(CalRecycle) VV � �I�i <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ++ --1 i Inspection Type(Fill one) <br /> Site Suffix: 1 I l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local cIf Referral,choose referral type(Fill one) <br /> Identifier: Su Y\ ('� ��, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ L Inspected By Inspector <br /> ���>> Y1�i,S. VcP,� C�.✓tr� L�IIc� <br /> Physical Address <br /> Inspection Date / / l <br /> Time In Time Out <br /> Business Rep Title O AM L, O AM <br /> L A PM Z �G O 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 ® Passenger ® Generator * Outdoor <br /> O Q Closed Q Altered <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 /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 o <br /> Q Q Other:§ <br /> Comments LL <br /> r� G <br /> Inspection Form Included: AN <br /> Comments Included.® 2o!l 56e Ad 7 <br /> Mle�Ws Signature Phone)Number j p t r' gna re Phone Number <br /> INSTRUCTIONS ON B [Correct: Incorrect: � a � E X A E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy EA <br />