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Waste Tire Ste_ ✓ey & Inspection Repor. Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 117 8 0 4 8 <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: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: C <br /> Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical <br /> sical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Titl` � e Li � �O AM j �1 � O AM <br /> ® PM ® PM <br /> o - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator O Outdoor <br /> -- --- --- — O Q Closed Q Altered NIA <br /> GPS Latitude O Hauler Q Indo <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) vo ll <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 W�l1QJ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> E <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Other:§ -- ---- - <br /> Comments f Q 1S <br /> fl o <br /> I tA a k) 3 J <br /> Inspection Form Included: Q 2n9 <br /> Comments Included: <br /> Business Rep's Signature Phone NumberInspe s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXA JLJEJ 11 121j] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py:L ® ■ <br />