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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> CalRecycle State of cle181(R I l e 1210224 <br /> CalRecycle 181(Rev.y(Cal 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: ` U ` l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC _ �� If Referral,choose referral type(Fill one) <br /> Identifier: �l ttf� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \\ Inspected By Inspector <br /> Ec c \e, <br /> Physic l Address 3 9 - t <br /> "_G'1 rrl UL S)r <br /> Inspection Date -7 / d / ? <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 J 0P a� 3 5 BPM <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 /> (0 © ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Auto Body Car Dealer U Collection 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 /> - - 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 /> 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 /> Q O 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 (0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> - z <br /> Comments <br /> S�e <br /> � a <br /> Inspection Form Included: Q C -7v <br /> Comments Included: <br /> Business Rep's Signature Phone Number rh de/Ttb- u Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M L 1 2' 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />