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Waste Tire Srujrvey & Inspection [Repork Inspection Report Number <br /> CalRecycle State of cle 181(R 11 - 1245296 <br /> CalRecycle 181(Rev.y(Ca] Survey Form - Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey - _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �/ 01 � � _ � � Inspection Type(Fill one) <br /> 7-Site Suffix: a 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ( /� C� C�Le �d 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �✓ <br /> Inspected By Inspectorector I 1,1�0e- _ (� Sip <br /> Physics Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Z : -2 <br /> U OAM <br /> PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count h le/PTE) <br /> /� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `/Z� <br /> 0 Active If Passenger If Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> CAPS LatittrZ 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> jo Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators JbIn Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments 044-" <br /> N <br /> tl ;- OL � e6VIr�. <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> a � <br /> - Business Rep's Signature Phone Number Inspectors ture Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: :X:*�q] E I X I A IMI P I L I E 1 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />