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2 Waste Tire S_ ey & Inspection Repo< < nspection Report Number <br /> Cal Recycle State of California I 1 - 1176418 <br /> CalRecycle 181(Rev. (CalRecycle) <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: p Z U Routine Re-inspection® Q P Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (_ � � CHP Q CalRecycle Q Complaint Q Educational Visit <br /> Q Other <br /> Business <br /> or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> F I O <br /> Inspection Date Q 1 Cr i I <br /> M�Cl/ti � A �j�3 3 to l ! <br /> Time In Time Out <br /> Business Rep Title <br /> //`` C) oZ � Q Q AM O AM <br /> l_f <br /> IJi OY-, i Y1 • PM " '3 L) O PM <br /> oWY'%Q.f . <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) S 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> 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 ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 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 <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 EXT N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years - <br /> 0 <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 Generators10 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 1n - <br /> f-G <br /> I Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature C!_�Phone Number Inspector's Signa tu a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: , E X A P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y:LE <br />