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Waste Tire Suovey p p& Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle — <br /> Y CalRecycle181.(Rev. (CO( Survey Form - Page 1 I1 1230201 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- o eEoose <br /> pe(Fill one) <br /> Site Suffix: A 5 Q C) li Re-inspection Q Referral Q Observation <br /> Local � referral type(Fill one) <br /> Identifier: D" �d ��`� Co Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physics c r ss ���• t CSS - I mN-T 7 <br /> - <br /> Inspection Date <br /> 5 �co�1 L f 1� 9SZOS 1 <br /> Time In Time Out <br /> Business Rep Title • AM *AM <br /> 9 30 QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> t ` <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ") <br /> 0 Active 0 Passenger 10 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <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 /> New 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX7) <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 o <br /> Q Q Other:§ z <br /> Commentsy�ciA\Ot-zt)h -cy4yckek wa- A-`ni& Ack awk Q "I�b WA M <br /> % S 1, <br /> Inspection Form Included: Q 01- 9/77�s <br /> Comments Included: i�� <br /> "[ T� <br /> Bu el S' Phone nspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7,oVjjEjXjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />