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Waste Tire Su, vey & Inspection ReporIL Inspection Report Number ■ <br /> cal Recycle State of California I 1 - 1196491 <br /> CalRecycle 181(Rev. (Co) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> i PID- ' S 0 Z _ O I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: �n �`� co v / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> Physical Address <br /> 2 y <br /> qs� ` Inspection Date <br /> Tia . <br /> Time In Time Out <br /> Business Rep Title IU AM 0 AM <br /> _ l4% a 0 PM V > J 0 PM <br /> FV'av\\L. M1 y A:� '; Cid 2 <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered I N <br /> GPS Latitude ,-'/„L Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck (` <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> '1 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> J 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 /> 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 /> 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 /> 0 <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 <br /> *In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments <br /> JyC7 ��a��aOv�S �� �P_a� c� �v�c.•2C✓1� <br /> -ispection Form Included: Q qq <br /> Comments Included: o� 8 d .��s a <br /> mess kReSignature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />