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Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br /> calRecycle State of California I 1 - 1196618 <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- Inspection Type(Fill one) <br /> Site Suffix: 6 $ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local cc __ \ L If Referral,choose referral type(Fill one) <br /> Identifier: �G(✓t JbGIl�l/�L /�( Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LOW P,n2 et- Mew use c, of - <br /> Physical Address (� A tai <br /> Inspection Date l <br /> V"1�t✓L E eco. �s33"1 0� <br /> Time In Time Out <br /> Business Rep Title 1 Q AM �7 O AM <br /> ( G <br /> � <br /> --ilVV1. �CG(i(.�(�,/ �e[M'lP�✓ ` 7 0 PM d-� � � BPM <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 /> J ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 <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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 Q Other:§ <br /> Comments <br /> Inspection Form Included: `'�✓" <br /> Comments Included: <br /> Business Rep's Signat re I Phone Number s ct Si nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct'0 Incorrect: zX W E A L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L © 0 <br />