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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California _ ■ <br /> CalRecycle 187(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 I1 1177804 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O o f © Inspection Type(Fill one) <br /> Site Suffix: l <br /> Q Routine Q Re-inspection Referral Q Observation <br /> Local ��� �^ 1 �� If Referral,choose referral type(Fill one) <br /> Identifier: J U fit 1 I u n Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address <br /> -\ _ Inspection Date <br /> 0&�rOn CA <br /> Time In Time Out <br /> Business Rep Title �FM M � � � � PM <br /> NJ c�W`[� V rn�'0 n,.r `C)C.Si Wcc►l Ga Ecl� <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 /> Q Active Q Pasnnger Q GeneIrator Q Outdoor <br /> QI <br /> PSLatitude O0 Closed Altered A <br /> G <br /> 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 /> 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 (� 1 <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 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 U) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <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 0 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 IS �Ul 1 r W4S <br /> Na v�v h1n �- bJ -u >cws Of_�on-urn - <br /> es'. a 's �b �-,'c,-r-) <br /> 'plc, us 50� <br /> � (��EnyloSlt+tlt,(rfUl IS`1 � C.►.�jfcf� �us�nGs� ��” �'r1u OGITIO(�-�I/AP✓ _ - <br /> Inspection Form Included: a A L.. '1 ��y,� L <br /> Comments Included: Q o :0" a? <br /> BusinS� <br /> e gn re Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: x �t E X A P E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co ® ■ <br />