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.� Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I - 1176452 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> P--t A- Survey _ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> ,,Ip_ - � I Inspection Type(Fill one) <br /> V <br /> Site Suffix: Xv ) ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��n JOCW w f1 CO"kn n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ Inspected By Inspector <br /> Qo�)4 1� M , �_OR <br /> Physical Address a Ct� D <br /> Ins <br /> Inspection Date <br /> _f(_6k_(,� v <br /> Time In Time Out <br /> Business Rep Title I 1 I ) ® AM 0 AM <br /> 1 l� 0 PM V v PM <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 Pasnlgeer Q Generator Q Outdoor <br /> O Closed Q Alte'revd " I N111GN/4 <br /> PS Latitude Q Haulel' 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 Q 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 /> 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 EXT) <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 /> 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/ t I.L ` c.\ G� l F�( '1() owl' <br /> '% ' ' k �i �\ i 1_ lNz S Clap <br /> —spection Form Included: Q ( <br /> Comments Included: Q `� �_"L10_o_�-_J <br /> Business Rep's Signature Phone Number Inspe t is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLEJ 1112L3] 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />