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Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of cle 181(R I 1 - 1177784 <br /> CalRecycle 181(Rev.y H0) 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: ` L� ''� O © l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local CC__ If Referral,choose referral type(Fill one) <br /> Identifier: �:tY� �cv� 1 Gam / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! Inspected By Inspector <br /> Physical Address <br /> CA <br /> qInspection Date <br /> �`'� Time In [ Time Out <br /> Business Rep f Title --7 ®AM O AM <br /> 1JYI��C�G�, il�ll�,,�eb®� Q!A/Ntt'i✓ � � � [ O PM � � � � 10 PM <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 ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR # End-Use Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station I* 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: 0 -_ /nO9)33 7, U2 <br /> Comments Included: l'L 5 7 <br /> Bu • s ep s Signature Phone Number sp t Si nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �J E A I L, E 1 2 N3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® ■ <br />