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0 2 Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 -1176823 <br /> CalRecycle 181(Rev.y(CalRecycle) <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey - - -- - -- - — - _-- BLU_E OR BLACK INK_P_EN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix I 1 3 { Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local C�i� If Referral,choose referral type(Fill one) <br /> Identifier: ` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address( \ _�-TT''_ 39 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ®AM <br /> I eAM <br /> U <br /> J O PM 0 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 /> Active <br /> Q Passenger ® Generator Q Outdoor <br /> PSLatitude • O ® ClosedQ Altere <br /> -"//,4 <br /> 4 <br /> G /AQHauler Q Indoor <br /> OQ Inactive Q Truck <br /> Longitude Q Planned Q OTR QEnd-Use <br /> Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 /> 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 1. 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 /> 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 v <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> r__42 r-� c>J _ Ala `+11ne..S r-A�eyY"-.��Li��r�' <br /> IN P c <br /> Inspection Form Included: Q - <br /> Comments Included: Q- - - ___� <br /> _ Business Rep's Signature _ Phone Number-_- s c r'__ use Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect_ (� �J E X A M 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co ■ <br />