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0 Waste Tire Sta. vey & Inspection Rspen Inspection Report Number <br /> CalRecycle State of California 1 T — /9 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page W 11 (at <br /> Dept of Resources Recycling and Recovery(CalRecycle) V{.�� V�i�J Page�i <br /> 5156 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � ` � � � � m � Inspection Type(Fill one) <br /> Site Suffix: 1 l 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ���;p Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �;� ��e��• �e5 1 \ <br /> Physical Address q L 1 MA U <br /> 7� <br /> S�c��� �� ��n �� Inspection Date I O / ® � / I S <br /> G Time In Time Out <br /> Business Rep Title O AM O AM <br /> M !- 2 0 5 QPM � ' �� QPM <br /> Los" �G t``` Operational Status Tire Type Business Role Storage Type <br /> ' <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 0 Generator Q Outdoor <br /> o Q Closed Q Altered <br /> ,�� Latitude Q Hauler . Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 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 0 Other Y`C_41 CeAklt'r�IITt�'16u <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 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 O 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 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <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 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 <br /> In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments o r <br /> 1 <br /> Inspection Form Included: O /ou^ <br /> '2— AO <br /> Comments Included: vt <br /> usiness p's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112L3j 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />