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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196452 <br /> CalRecycle 181(Rev. (Ca[ 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` Inspection Type(Fill one) <br /> Site Suffix: 1 _t v 1 '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �ta (fin Q �� co V^ / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _-4 Inspected By Inspector <br /> Physical Address 2, � \ v <br /> Inspection Date <br /> 10 / - <br /> Time In Time Out <br /> Business RepItle O AM I O AM <br /> `jW� YQ�f�Fc� I Z 0 PM 0 PM <br /> VVV\ W - - 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 /> ' 40 Active Q Passenger • Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 16 Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) j <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 7- C Ml1,wvtGA'3rlzC <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 /> 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 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 <br /> 2 <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments,S�n��:I C`�"oV\c_ ny\ <br /> v S v�G2 <br /> Inspection FormIncluded: Z� ` <br /> Comments Included: fj 41494* � <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> X NJ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />