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Waste Tire Survey & Inspection �LL� s,c,psort aiispection Repor` Number ■ <br /> CalRecycle State of California( I 1 <br /> CalRecycle 181(Rev.y(Cal S rvey Form — P ge 1 1177998 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey W© �a9 © II d� Page <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 / - p� I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalL If Referral,choose referral type(Fill one) <br /> Identifier: S�n ��tA)J_\ �to 'f4 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address` ' Es oto <br /> Inspection Date / a ! n ) 0� <br /> \ G.SMin�TD� Ctat �SL3� VV <br /> Time In Time Out <br /> Business Rep Title 0 O AM ] rO AM <br /> ( O *PM "`' 7 O PM <br /> �� r 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 /> • Active Q Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® 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 ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 <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 EX7) N <br /> _ a <br /> 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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ z <br /> Commentstot-, a N <br /> �WKI L v <br /> Inspection Form Included: Q �oa •/7� ,y <br /> Comments Included: la <br /> s' VReps Signature Phone NumbAr Inspe t is Sign re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ZQ W � E X A E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CV <br /> ® 0 <br />