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Waste Tire Stagy vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 1 1 1255934 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- 2 _ Inspection Type(Fill one) <br /> Site Suffix: d 4 I Q Routine 49 Re-inspection Q Referral Q Observation. <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: C�v — Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> p �- /� ? (� Inspection Date I / 1 S <br /> 0.�`' _ 0,_ •�3 " Time In Time Out <br /> Business Rep Title ® AM ` e C� O AM <br /> c 1 O PM ` o 0 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 /> �7 <br /> / ' 0 Active III Passenger 0 Generator * Outdoor <br /> o Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 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 m <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 EX7) 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 /> 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 � ,r1 .�---��--�•��, 4 ��S lJ��� Com. (�'Ttn� 1 O�IIC�la1 h <br /> N - <br /> �rev: <br /> oc a er <br /> Inspection Form Included: Q /J�'-264"vg-37- <br /> 32- <br /> Comments Included: Qsiness Re -`'/ <br /> Bup's Signa ure Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: _ * q71 <br /> IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA . <br />