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0 Waste Tire Su. ,✓ey & Inspection Report inspection Report Number <br /> CalRecycle. State of California <br /> (R 1�_ - 1230362 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t 7 t ,1 G _ O t Inspection Type(Fill one) <br /> Site Suffix: " t 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> MCXY\ \ <br /> Physical Address (� MT T (V <br /> CA -1< Zzu; Inspection Date /� / Q -2- <br /> Time <br /> Time In v Time Out <br /> Business Rep Title 2 O AM Y S 0 AM <br /> c O PM 4 Q 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> o Is Closed Q Alter r"l� �/fA <br /> GPS Latitude J� � (Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 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 /> 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 /> 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 Exf) 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 Q1 Other:§ <br /> Commentsh �\Ct4(N�� <br /> 4 n 3-O o <br /> Inspection Form Included: Q <br /> Comments Included: <br /> mess Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />