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® Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1177835 <br /> CalRecycle 181(Rev. (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- _ I Inspection Type(Fill one) <br /> Site Suffix: 1 © ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local �- I If Referral,choose referral type(Fill one) <br /> Identifier: SOLO J (),!4,1 u1-1-N CbU-OffiO CHP Q CalRecycle Q Complaint Q Educational Visit O Other <br /> Business or Facility Name _j p Y p <br /> Inspected B Inspector <br /> V I s S Cl Uss 'TcacC, <br /> Physical Address 3 1 0 , C's eb►�UUU'7 <br /> �0(b C ana btAnczF t� , """ <br /> Inspection Date <br /> TsCk (A qs3� 3 I 3 <br /> Time In Time Out <br /> Business Rep Title 'a, 0 AM 0 AM <br /> E� b � <br /> S QPM 3 � � is PM <br /> tl�Ji � Sv, -c ��l�c f' <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 /> ® Active Q Passenger 0 Generator A Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / M / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 46 In Compliance-No Violations <br /> O O Other:§ <br /> Comments <br /> Inspection Form Included: Q� ' <br /> Comments Included: - �q� <br /> Business Rep's Signature Phone Number Insp or's Signatur v hone]Number b <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X*::V:]I E X 1A M.R, L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L © 0 <br />