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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle state-,California 0) 11 - 1226264 <br /> CalRecycle 181(Rev.10/1 <br /> Dept of Resources Recycling <br /> e y ling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- _79 Inspection Type(Fill one) <br /> Site Suffix: 01 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cc 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address C) 'I <br /> Inspection Date <br /> i-v�ncl-' C.,VL' I Time In Time Out <br /> Business Rep Title 0 AMO AM <br /> 40 PM 5_ 46 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 4b Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 Inactive 0 Truck 0 Hauler Indoor <br /> Longitude 0 Planned 0 OTR 0 End-use container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EX7) C? <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 /> 2 <br /> Lu <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 <br /> 10 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 Business Rep's Signature Phone Number jRslpdctKs,1fighature Phone Number <br /> -] III -I <br /> INSTRUCTIONS ON BACK Incorrect: EXAMPLE 3 62081 <br /> MWhite Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA M <br />