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Waste Tire Su. rey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1229926 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - SurveyBLUE OR BLACK INK PEN_ <br /> IBusiness Profile Inspection Details <br /> TPID- I O Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (7 Inspected By Inspector <br /> Physical Address <br /> - <br /> C ���� Inspection Date O / 26 / I S <br /> t SOL Cy Time In Time Out <br /> Business Rep Titl e n 1 � � SAM AM <br /> MQi�,_ O PM ` L 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 Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive A* Truck <br /> Longitude — Q Planned 49 OTR O End-Use Container <br /> Business Type(Fill all that apply) _ <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet 0 Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture O 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> O O Other:§ <br /> Comments <br /> V��l.b2a-sem- �✓���C h �O Y`{2-(�ti�� -� .� <br /> CAS YA <br /> �1 --fie <br /> Inspection Form Included: <br /> Comments Included: <br /> iusiness Rep's Signature Phone Number lnspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X AjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />