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N 1 <br /> ® r 2 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Y�fleCyCle State of California I 1 1176420 <br /> CalRecycle 161(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 /> oiness Profile Inspection Details <br /> i PID- Inspection r 2 3 _ Q r Inspection Type(Fill one) <br /> Site Suffix: t !T * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. i> - Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1� c Inspected By Inspector <br /> J <br /> Physical A6dress <br /> Inspection Date <br /> 1 r��`� Cr'� cls •3�� <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> d 12 ® PM d oZ S 0 PM <br /> �C6aw k uvf�G�Sgrt i C k� �ss;r� jpce,,,r,,krv� <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 <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 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 /> v 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 CfCGt�I'vLar <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> � <br /> - - -- — - - <br /> V A HAULING AND MANIFEST REOUIREMENTS <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 /> 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 EX ) 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 /> 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 <br /> Q 1 Q 1 Other:§ ..__ <br /> Comments 4Jtr z <br /> rA _'� L1� ,y� C GrCCC ' <br /> G"ll34 41-AA 40_kul-`-yi�l iAv& C fit 0}ccs -- - <br /> a—pection Form Included: Q <br /> x-[68 <br /> Comments Included: - - (-Zoe, Z3 <br /> Business Rep's Signature one Number or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 62081 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />