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Waste Tire Survey & Inspection Report ,rispection Report Number <br /> State of California <br /> CalRecycle 11 - 1177808 <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- ' 1 , ' 1 _ Inspection Type(Fill one) <br /> Site Suffix: Q Routine Q Re-inspection ® Referral Q Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: n Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Ad ss <br /> Svo � <br /> r Inspection Date <br /> �'/`J���� V Time In Time Out <br /> Business Rep Title O AM O AM <br /> I. ' 1 5 0 P ' 3 S IDPM <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 Paoenger Q Generator Q Outdoor <br /> GPS Latitude 0 ® Closed Q AltereN <br /> p IA N14 <br /> Q Hauler Q Indoor <br /> 0 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 N,04 <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 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 EXE 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 <br /> In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> cis, <br /> � t � J <br /> errp4-vA- C 0 S P, <br /> Inspection Form Included: Q " <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number lnspp&ors Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: 7X707q] EXAM I P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />