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Waste Tire Stvey & Inspection Repor ,, Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245222 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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: QJ ® Routine QRe-inspection Q Referral <br /> Observation <br /> Local 3r <br /> If Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr&esse)YVA f U J 5 <br /> i4j <br /> r Ad Inspection Date y / r 5 <br /> slbf)� Time InTime Out <br /> Business Rep <br /> Title O AM <br /> QPM � I _ ` —0PM <br /> 6pe'tational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/P (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ®Passenger ®Generator ® Outdoor *7>. <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive O 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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) C? <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 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 OIn Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments Tzwl�l , N <br /> Inspection FormI4,ncluded: <br /> - - <br /> Comments Included: <br /> siness Rep's Signaturea Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM L 1 2131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />