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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California <br /> CalRecycle I1 - 1230142 <br /> CalRecycle 181(Rev. (cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-_Su"---- --- - - - <br /> Business Profile Inspection Details <br /> TPID- , m 3 r u u - © I Inspection Type(Fill one) <br /> Site Suffix: lJ (0 i Routine Q Re-inspection Q Referral Q Observation <br /> Local �\ / If Referral,choose referral type(Fill one) <br /> Identifier: Sp�l� Jowtiu�'� C�vbn Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> t'a,.(,� M c�Co r b r e <br /> Physical Address' 3 <br /> - Lwo N c)1 _ - <br /> �S� Inspection Date <br /> Time In Time Out 1 <br /> Business Rep Title L1 1 I : U 0 B AM 1 22 0 AM <br /> W C�,(c1 _ ` [T I`T'S fade>>s� 0 PM L I J v O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> aE- <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q yispleennger Q enerator Q Outdoor <br /> O ®Closed Q Altered �A N 1,Q <br /> GPS Latitude Q Hauler Q Indo F 1 <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 / V�� <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 EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 1 Q Other:§ <br /> Comments �UIJC, iJ._, (J4100 JCS l�l�l�" <br /> y 1 <br /> �1 <br /> ! I� In(fl etJ,= �eCj L�/101 a 1 �1 OJ Q j p v►S o�C�n •._ <br /> S rl"o �!%'r%\1e1' (�US e1' 4 <br /> I C,� D U��i <br /> TR!P 7- lel ug3S_o l _ -f sb <br /> Inspection Form Included: Q - <br /> Comments Included: Q � I hl ('_) �GO��� -ek <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLEj 1112L3] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />