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Waste Tire SL.. vey & Inspection Repor, Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 12 3 0 0 5 4 <br /> CalRecycle 181(Rev.Recovery <br /> 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- q _ O Inspection Type(Fill one) <br /> Site Suffix: 1 I ; Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �ato -,ToCJL C0U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> See-Q-A H t-_L cx ( D 1 as cow v <br /> Physi �dless I /� 3 1 - <br /> 4,6.,�� q L a/k a c.a, L. ). <br /> LO� �� 9Sz�'llc� Inspection Date L4; <br /> Is-"AD <br /> Time In Time Out <br /> Business Rep Title I : d Q •AM I : ® AM <br /> i- O PM L O PM <br /> �o�r✓� un <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 /> e Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <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 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 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 <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 <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 IS In Compliance-No Violations o <br /> Q Q Other:§ 1I11 y <br /> Comments �l11�Gt.l ya�G�'e. �I er f1� <br /> No OI u i S (;f- n=N. rn <br /> Inspection Form Included: Q <br /> Comments Included. Ak ���� <br /> Usines ep's Signature Phone Number Ins ctor's Signature Phone Number <br /> �,{ 62081 <br /> INSTRUCTIONS ON BACK Correctr>♦ Incorrect: � W �J E X A M P L E 1 2 3 <br /> White Copy:CalRecy_ Yellow Copy:Operator Pink Copy:LEA <br />