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OZ Waste Tire Su, ,iey & Inspection Report ..ispection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1210 519 <br /> CalRecycle 181(Rev.y(Cal 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- 1 S 1 Q - p� Inspection Type(Fill one) <br /> Site Suffix: ` ` U * Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: S&n"')'0C4,jtA11f) (01A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> En coy, jrnc_ 3 <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep y 1. Title <br /> /l ® AM <br /> 0 AM <br /> 1 l 1 5 O PM <br /> 1 O � V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O e Active Q Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) 1 <br /> Q 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other N U,QAU'16 16 �`/�,N n-4im}�ww <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 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 a <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle q <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement :f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (f In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments L 1 1i N <br /> 69- 0 r)��nl 5 Lfw_ qn(4 \AILS )nnlJ�- <br /> Inspection Form Included: Q ' �( k <br /> Comments Included: — F` '-g -�� — - - — �� "+� <br /> Business 's Signa Phone Num er Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M A JL[Jit1112 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink C py © ■ <br />