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Waste Tire Sup Bey & Inspection Report :11spection Report Number ■ <br /> State of California <br /> 11 - 1210307 <br /> CalRecycle 181(Rev.y H0) 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_ U ` Inspection Type(Fill one) <br /> Site Suffix: ' q 1 S ` ' Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y� 7c::, '%3%VN C�v� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Bu/si�ness or Facility Name Inspected By Inspector <br /> Physical ddres ��e�J �`�C —I <br /> 1'2 S 'I /I 0. <br /> Inspection Date � / 2 � / 1 <br /> �Ole-Vn>n CA- `I5 2 C15 <br /> Time In Time Out <br /> Business Rep TitleAM <br /> Q O O 1cD <br /> 1 , AM <br /> p Q PM 6 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 A (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> S 4P Active * Passenger &Generator * Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> 0 Q Inactive * Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 1@ In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments \� _ Pec :av� ��oh2 eve l S <br /> Inspection Form Included: O �G �/ y <br /> Comments Included: �<d �W _d2 2�-"ib$�3j� <br /> Business Rep's Signature Phone Number Insp toy's Signature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � NJ I IEIXIAIMIPILIEI 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />