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2 Waste Tire Su, vey & Inspection Reporn Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1210241 <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: ` 4 Ll 1 q 3 L ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sw% C,,,c IV\- "V., % Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S:. e_L)Ca <br /> Physical Address <br /> Cil R536w�- Inspection Date 1:� / 1 / 1 �S <br /> Time In Time Out <br /> Business Rep Title 0 AM ® AM <br /> i ( j a QPM ( -5 Q QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive a 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ® 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) <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 W <br /> Q Q 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators 0In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> )ee_- ry <br /> ��-7;lv <br /> Inspection Form Included: Q <br /> Kb <br /> Comments Included: / I y �6� <br /> usin ss Rep's Signature Phone Number Ifi ecto ignature Phone Number <br /> � � <br /> INSTRUCTIONS ON BACR/ Correct:0 Incorrect: 7V � E X A M(P LIE 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />