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Waste Tire Orve & Inspection Re or0lnspection Report Number <br /> CalRecycle y p p <br /> y State of California I 1 - 1245321 <br /> CalRecycle 181(Rev.y(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: tL1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: j� J 0gg0(� C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `' Inspected By Inspector <br /> Physical Address ( ) O 1 <br /> Inspection Date <br /> y (/ <br /> Time In (((JJJ Time Out <br /> Business Rep Title � O AM i O AM <br /> ��{� GI � r ®PM _ � � QPM <br /> SSa,i1 �, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Coule/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> n (Wh <br /> Q Active 0 Passenger ® Generator i Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive •Truck <br /> Longitude — Q Planned Q OTR Q End-Use 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 0 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 /> QQ 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 EXT) N <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 On Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments < <br /> CtQ <br /> Inspection Form Included: Q 'Orl <br /> Comments Included: <br /> ss R ignature Phone Number I spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: jEjX�AjMjPjLjEj 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />