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Waste Tire Survey & Inspection Reporn Inspection Report Number <br /> CalRecycle State of California 11 - 1255729 <br /> CalRecycle 181(Rev. (Ca[ 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 O � � O � Inspection Type(Fill one) <br /> Site Suffix: f 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: 150-V1 J C3" V;r�' Coa,,Ai Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name A,, \ Inspected By Inspector c� <br /> Physical Address <br /> Inspection Date <br /> 15 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 5vG <br /> ` 1 Z 0 * PM 2- &PM <br /> i ►i ptP�t�� �. <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active Q Passenger 10 Generator Q Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler 40 indoor <br /> O Q Inactive a 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 0 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 <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXEC? <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 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 • 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 19 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> QLv.c sZ OW��.3.A.S Ytti <br /> e �S <br /> Inspection Form Included: Q �9�°&-- <br /> ,;,, 20 9��6g-3Z8 y <br /> Comments Included: <br /> Bu n s RA's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � IIIIIIIIE X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />