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Waste Tire Su. rey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210 516 <br /> CalRecycle 181(Rev. (Ca( 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- q 3 ^ _ Q Inspection Type(Fill one) <br /> Site Suffix: 1 �! 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �-- 1 If Referral,choose referral type(Fill one) <br /> Identifier: &n 0 CHP 0 C lRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> f � �� � Inspected By Inspector <br /> n <br /> 1)Os VJ C3f\ �s <br /> Physical Address 1 n J _ 1 d , CS((� � <br /> S LI O N. �ca C1� - S v�t�r✓ l 1 <br /> G�oC�&o rN QC Inspection Date / z o <br /> lJMt Time In Time Out <br /> Business Rep Title I ® AM Q AM <br /> Ov,,u12,\0 0 w C) , <br /> QPM � O O ® 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) uJ�G <br /> 0 New Tire Dealer ®Auto Repair 0 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 0 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 /> 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 <br /> M / m / 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) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *in Compliance-No Violations o <br /> 0 1 0 1Other:§ <br /> z <br /> Comments ,LX\\1;ak I <br /> an er i I ✓r-- o I 1 <br /> u US <br /> ��, 41 0r Goal f e,1n- <br /> Inspection Form Included: 0 <br /> Comments Included:is ;!` <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />