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Waste Tire SL.. vey & Inspection Repor► Inspection Report Number . <br /> CalRecycle State of CaliforniaI 1 -1176849 <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: L; I. ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name // <br /> Inspected By Inspector <br /> Physical Address 9 <br /> Inspection Date <br /> j 6 CA (�� `'J o Time In Time Out l l <br /> Business Rep Title ) J ® AM AM <br /> - / c 0 PM 1 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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered A,114GPS Latitude At/A 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> I <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / FT / 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 EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> W <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 o <br /> 0 0 Other:§ <br /> Comments <br /> �,.�'1f' ��S�c�fi z� lr� � �rr/m 2{~� rs,1 --II�t,� r�--:r,�z' �L�© 1,✓. ��c:....>�GY?S �, <br /> _i, GZ)Y_ QC� <br /> �� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ " �bFAX 7-t <br /> Business Rep's Signature Phone Number I c Ig tur - Phone Number <br /> - --- - 620111 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I E I;4A/*LP,4l?j I 1 12 13 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />