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Waste Tire Su. ,iey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1229956 <br /> CalRecycle 181(Rev. (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- ` � d Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �by�r b� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> fires 5 D% - 1 a 1 )11/\'11\T7 v <br /> S goo W • �a�ti.`sa�O �2. __ - - __ <br /> Inspection Date Q Z / l S ) S <br /> Laa. �52y <br /> Time In Time Out <br /> Business Rep // Title O AM O AM <br /> U� <br /> SOPL I S PM 2- 2 S 461.PM <br /> V� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) , D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 10 Passenger •Generator 0 Outdoor <br /> 0 Closed Q Altered <br /> GPS Latitude Q Hauler ! Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR o End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4D 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / Ffl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators fin Compliance No Violations o <br /> 1010 Other:§ <br /> Comments v S C S OVA <br /> T a- ar <br /> �f._�p w► wC t ,.�c,�S k <br /> Inspection Form Included: Q / If J ;O J" <br /> ` '�[/ <br /> Comments Included: 0 <br /> usiness Rep's Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />