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Waste Tire Su. rey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196515 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> r t A-Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> I PID- � � / � I � 1 t - � � Inspection Type(Fill one) <br /> Site Suffix: b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> r �yyL Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ��V <br /> 2 x'1,2 �� �,a.ccGA �- ��. <br /> `�O•, Inspection Date / , / I <br /> 'Tvo-Ly J y Time In Time Out <br /> Business Rep Title 0 AM e A AM <br /> O QPM 1 Q (=� 0P <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 /> )25 Q Active Q Passenger Q Generator Q Outdoor <br /> * Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair • Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> .� 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 N <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 /> N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 Q w�.�nQ_ Wo•�S� 'i'�'��. �,;��P�G ��� gp� c5y�, 'CV�.�S Q�,� Ah� �� �, <br /> "� � ���c�- o.•n�-C' v'l�;c c,;.�� �o���a_C�¢ 20°1-$31-6�0 owt�`c� �l ose <br /> .ospection Form Included: Q t' <br /> Comments Included: Q �Signture <br /> 2��^Tb�"�2Business Rep's Signature Phone Number InpePhone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ZN W 62081 <br /> E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />