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-Wa--st-,e---Ti-r ,e-.Survey—&-In-s,-pection Report Inspection Report Number <br /> CCalRecycle State of California 0) 0 <br /> CalRecycle 181(Rev.1011 1210534 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> A-Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> TFID- Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identif ler: 5ew\ 76 cLj Q\%ir\ Cc:,Q, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 2 7 3 <br /> Time In Time Out <br /> Business Rep Title _Z 5 1111111 AM Z AM <br /> 0 PM C) 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 &Closed 0 Altered 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 container <br /> Business Type(Fill all that apply) <br /> qew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 /> 0 0 PRC§42951.-Waste Tim Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 <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 EXT) <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — Lu <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 4k in Compliance-No Violations <br /> 10 1 0 1 Other:§ <br /> comment%q% <br /> A <br /> - <br /> C_C�>VIA I&I <br /> spection Form Included: 0 <br /> Comments Included: * <br /> Business Rep's Signature Phone Number InspecGr's dignature Phone Number <br /> INSTRUCTIONS ON BACK jCorrect:6 Incorrect: "7 IEIXIAIMII 62081 <br /> X V] <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />