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03 Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177705 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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- Inspection Type(Fill one) <br /> Site Suffix: <br /> I 1 5 4 Q Routine Q Re-inspection ® Referral 4*bservation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: ,yL ��CCcf�..tV\ ��v"L Q CHP Q CalRecycle® Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �U � -�- art►'l>�'Ylt;t�1/l T�".� /`7/� �(� �JJ <br /> Inspection Date <br /> TC1_- <br /> Time In Time Out <br /> e Title <br /> Business R1 �f) 0 AM 0 AM <br /> ® PM 12 (--5- wpm <br /> Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) F <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J <br /> ® Active f Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O 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 /> 49 <br /> Q Service Station Q Hauler Q Agriculture . Q Shredder ® Other lot - 4-6 - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> �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 /> I Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M-7 / <br /> ® Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 0 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXTJ 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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance- No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q / 'C v <br /> Comments Included./@ <br /> Bus ess Rep's Signa re Phone Number ns tor' S' nat Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � E A M E 1112 <br /> 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />