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Waste Tire ..jrvey & Inspection Repc. ,L- Inspection Report Number <br /> State of California <br /> CalRecycle 1 1 1245135 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <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: `� o c / 4$Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: . (� CC Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or <br /> Facility Name �y�. Inspected By f ( Inspector <br /> ( <br /> Phys is I Addre fur <br /> / 3 �l [ U / J W i' Kt <br /> Inspection Date � / Z �J � � 5— <br /> Time <br /> Time In Time Out// <br /> Business Rep Title l O AM O AM <br /> ALA f" F n v 2" 0 PM Z is PM <br /> j�wayi (XQd(,© perational Status Tire Type Business Role Storage Type <br /> Tire Count(Whol /P)E ;5 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger Generator -Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Ccntainer <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 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 /> 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 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 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 a In Compliance-No Violations o <br /> Q 1 Q Other: e- <br /> Comments <br /> . > ,, G� <br /> IV Q D <br /> Inspection Form Included: Q JOD 2 / <br /> Comments Included: <br /> Business p's Signature Phone Number In' 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � V EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />