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Waste Tire S&ey & Inspection Repoi , Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245257 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept Recovery of Resources Recycling and Recove (CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � )�„ � � � � � Inspection Type(Fill one) <br /> Site Suffix: U ( 1 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> c � � Time In v Time Out <br /> Business Rep Title ®AM O AM <br /> �j�� 1-i�1Z(Q, I d 0 PM z— 6 GPM <br /> r udd I -Operational Status Tire Type Business Role Storage Type <br /> Tire Count ho /PTE) l� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V� ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latit e Q Hauler Q Indoor <br /> Longitude O Q Inactive 0 Truck <br /> Q End-Use ContainerQ Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 EXE <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 *in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Ld-7 <br /> Comments Included: o <br /> BuXness ep's Signature Phone Number Inspector's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: —4NJ E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />