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Waste Tire SAey & Inspection Reporpinspection Report Number <br />CalRecycle State of California 11. — 1230282 <br />CalRecycle 181 (Rev. (CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - / I <br />Site Suffix: ` S $ l7 Q <br />Inspection Type (Fill one) <br />` <br />0 Routine Q Re -inspection Q Referral Q Observation <br />if Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: ah To V IN, COM6 <br />Business or Facility Name <br />Inspected By Inspector <br />I <br />ss Cov.cck)e'_ Sv@t <br />Physical Address <br />'?I- 1 C_"I f V a Tv <br />Com- C 9 SZIS <br />Inspection Date © ` 9 � I <br />Time In Time Out <br />Business Rep Title <br />f AM O AM <br />i I 5 <br />c r ^ <br />J� � �� �C�` 9ta� ` <br />O PM 410 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />2 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />• Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />Q Outdoor <br />Q Indoor <br />GIPS Latitude <br />Q Inactive <br />, Truck <br />O <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q 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 0 Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / m / m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EX7) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />Q <br />1 Q <br />Other: § <br />Comments <br />w4 -9j � o <br />''ave a c C cel' <br />Inspection Form Included: Q <br />% c y� <br />Q I <br />Comments Included: <br />—e f <br />Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br />�( 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: � � NJ EXAMPLE 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />4 <br />>9`I <br />