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P <br /> .Waste Tire Su. ,iey & Inspection Report inspection Report Nl.rube[ <br /> CalRecycle State of California 1 1 m 12 4 2 2 0 0 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form <br /> i1 © Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Edi 11 @Y ��fl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> (� <br /> Site Suffix: , -1 -1 7 4 d 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 710 N5% <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address 1 0 1 MAI ry v <br /> C� 9s Z�S Inspection Date � � / 0 -2 <br /> Time In Time Out <br /> Business Rep Title N e O AM O AM <br /> Z J ® PM ® 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 Q Passenger A Generator Q Outdoor <br /> O Closed Q Altered Aj{/ <br /> p <br /> Latitude Q I <br /> O Q Inactive Q Truck Q Hauler Q ndo r: <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) vloav <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 J <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 <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 /> a <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 /> 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 1 Q 1 Other:§ <br /> Comments <br /> Y\ <br /> Inspection Farm Included: Q 1 t AD 2� <br /> Comments Included: ® ` J `0V `�i�OQ �7C.0 I <br /> iness Rep's Ignature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: q �jEjXjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA _ ■ <br />