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Waste Tire SL_ ✓ey & Inspection Repvri., Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1176457 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA--Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q � � � � � � - � I Inspection Type(Fill one) <br /> Site Suffix: ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S A(� J ga <br /> l iar-" owl Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> II— Inspected By Inspector <br /> bC1�A,- <br /> Physical <br /> `Physical Address <br /> V <br /> n Inspection Date 3 / 1 l l <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' QPM O V QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /J( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q <br /> � Generator Q Outdoor <br /> N <br /> GPS Latitude 0 ® Closed Q Altered/ Q'Hau 11� Q InS 4 <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 W 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 <br /> 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 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 o <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 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 (lK►�I'0rh i f N <br /> Wicks r r� <br /> iy! ;& W-S&A �Ilse TftU_ NJ,Lu 7Uf ;m5t1 <br /> Inspection Form Included: Q ? <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: A � q] I <br /> E X A L 111 <br /> 1 2 L3 "081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: © ■ <br />