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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1196533 <br /> CalRecycle 181(Rev, (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> - Survey BLUE OR BLACK INK PEN <br /> >iess Profile Inspection Details <br /> TPID- I � � � 1 Inspection Type(Fill one) <br /> Site Suffix: 4`0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5.-v\ �O Urn C V 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name i Inspected By Inspector ' `" ' <br /> Physical ddreG`s -0 ' -Y\ L©Yh(�C�.Y� 39 <br /> I d l /�� \ 1 V <br /> �& 95 Z ` <br /> �jT` ` Inspection Date 9 / © G / <br /> C9�'��V_\ � Time In Time Out <br /> sinesssr\R,eSp Title , *AM I I : 3 : ® AM <br /> QPM QPM <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 /> O &Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> P-siness Type(Fill all that apply) <br /> Vew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> U 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 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 <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) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IS In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments Lha}iCA� C'_--� <br /> of cc�.cs��o� Cohcec� - <br /> cC'Vy\ <br /> Inspection Form Included: <br /> Comments Included: - Z <br /> Business Rep's Signature Phone Number Insp ctor' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: \ � E X A M P L E 1112L3] 62081 2 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />