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t <br /> Oa Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196546 <br /> CalRecycle 181 cover (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> F- - A-Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> 1 r1113- 0 � ,y � � � -7 - O ` Inspection Type(Fill one) <br /> Site Suffix: "� 1 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ccv Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address <br /> Inspection Date 1 / Q1 / 1 3 <br /> Time In Time Out 1 <br /> Business Rep Title O O AM 2 O 0 AM <br /> 0 PM 0 PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE „( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ftl� Q Active Q �$ ger Q Genertor Q Outdoor <br /> ` <br /> O 40 Closed Q Altered <br /> GPS Latitude Q Hauler Q Ind or <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 /> Jew 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 EXTJ N <br /> a <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 /> 2 <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 ` <br /> ospection Form Included: Q <br /> ?p 1 53► �s3K�� - 2°`��`�i�-3 2$�1 <br /> Comments Included:40 <br /> - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: 1 Incorrect: � � EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />