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03 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle state&California 11 - 1196640 <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- I Inspection Type(Fill one) <br /> Site Suffix: / 6 -lq S 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local c / / If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ( Inspected By Inspector <br /> lov <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> 40 AMAM <br /> �`r <br /> < < � O QPM � Z C7 T QPM <br /> �I S �.�ts �c�'vl'� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger * Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GP� Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned &OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair iW Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other -� v� � '"'[ <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 /> - - 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments ` <br /> Inspection Form Included: <br /> J r• <br /> Comments Included: <br /> B siness Rep's ignature Phone Number -Sd�cp6Ks S' nature Phone Number <br /> INSTRUCTIONS ON BACK FCorrect.0 Incorrect: x E X A PILIE1 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />