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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> calRecycle State of California 11 - 1210111 <br /> CalRecycle181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> P`A-Survey <br /> ess Profile Inspection Details <br /> TPID- I l A � _ © Inspection Type(Fill one) <br /> Site Suffix: _t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �d���� V -� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> oc�'S MA-;A 3 q <br /> Physical Address <br /> Inspection Date <br /> CA <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 1 * PM , 2 0P <br /> - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) A[ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> <5V 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O * Closed 0 Altered NIA_ A114GPS Latitude N 0 Hauler 0 Indoor <br /> O 0 inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Jew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> L, Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m a <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> U, <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance No Violations o <br /> 0 0 Other:§ __ <br /> Comments <br /> C c f- c_C' <br /> was <br /> N..zipection Form Included: 0 A <br /> Comments Included:✓♦ <br /> Business Rep's Signature Phone Number insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />