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® � Inspection Report Number <br /> Waste Tire Survey & Inspection Report p <br /> CHIR cyda State of California 11 - 12 4 2 3 6 7 <br /> Dept l9 u u� CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Forrn Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA-Surv.ey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- —I 1 e C Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \scky" a 0'1 _- <br /> V'M Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> V�r <br /> Business or Facility Name 17 Inspected By Inspector <br /> Cozad '` ,pec �a�es , ALL 3 cl _ 1 o 1 MATT v <br /> Physical Address <br /> kA907 F, Wci, cv � , <br /> Inspection Date o <br /> gSZIS LJ <br /> Time In Time Out <br /> Business Rep / 1 Title O AM O AM <br /> ��� 2_ S 5 0 PM PM <br /> lJ � <br /> e `4 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 Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q 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 T <br /> �`�r cep <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q § - — Q Notice Of Violation Q Extension <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 / 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 EXE N <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 /> Lu <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:§ <br /> Comments <br /> Inspection Form Included: Q ��X I II&W -0-461k,3224 <br /> y, <br /> Comments Included: l7� <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone X �J Number <br /> �-�( <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />