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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cal Recycle State of California 11 - 1255847 <br /> CalRecycle 181(Rev. H0) 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- G Q - Inspection Type(Fill one) <br /> Site Suffix: I ? $ O Z l 6 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: � <br /> Y\.CXr v� � - OCHP OCalRecycle 0 Complaint OEducational Visit OOther <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address MA 1 <br /> Inspection Date 2- <br /> Time In Time Out <br /> Business Rep Title O AM I Q AM <br /> I L 5 ® PM e PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ,,[ <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (r/, <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O *Closed Q Altere�� AU�// )VA <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - 0 Planned Q OTR O 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 Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ------ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / 7 / M <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comment*L,,,,,\ <br /> �vt <br /> oz, bQ!R5 GOvqec ,n N <br /> ` 1. i tx�Y tr 4z CQS\ q C. 'W 4 <br /> Inspection Form Included: 0 <br /> Comments Included: Q E / <br /> Business Rep's Signature Phone Number Insp toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: X J� EXAMPLE I 11 2 3 62081 <br /> hit e C y:CalRec Yellow Copy:Operator Pink Copy:LEA <br />