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02 Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California11 -1176751 <br /> CalRecycle 181(Rev.y(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- � inspection Type(Fill one) <br /> Site Suffix: a —1 a 1 t $ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � j_ If Referral,choose referral type(Fill one) <br /> ��� <br /> Identifier: �C.L1n ct�� CC -A�v (j 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> lam►\c� CeY�,lu,���►� L'�r,P�;v�„ ,b-n � �, _ C� L <br /> Physical Address l <br /> _ Inspection Date / 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ® PINI q ' if / 40 PM <br /> 0&'-w t �rIQrS`p� qy1{ �J�Vl�Cr1CvOperational 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 /> 0 Active 0 Passenger 0 Generator 0Outdoor <br /> D 0 Closed 0 Altered A/' IA <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OT.R1 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other (ILIN,U -t-���� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use-Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> el /7 <br /> Inspection Form Included: <br /> Comments Included: W- t� ­ Pone Number <br /> �21 �6mb <br /> !Business Rep's Signature Phone Number In a tor' i n to Phone <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: t, � q E X A M 'L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:111141 <br /> © 0 <br />