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Waste Tire Su. ✓ey & Inspection Report -Inspection Report Number <br /> Cal Recycle State of California I 1 - 1177765 <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� � � , � _ o I Inspection Type(Fill one) <br /> V <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: , Y\ J� a V kV'N V nay O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> g odress--i 1��s 1 g 3 <br /> Physic d <br /> I5%A6 (qac►�zC c,,ve I r <br /> CA- g526i Inspection Date S o I 3 <br /> Time In Time Out <br /> Business Rep Title OO AM ' O AM <br /> PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 i Closed Q Altered' /Avl� A)/-j <br /> GPS Latitude <br /> O Q Inactive Q Truck Hauler 0 Indoor <br /> Longitude - O Planned Q OTR O End-Use Q 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 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 010 1 Other:§ <br /> Comments i� ! ` oyl' �,� 1� Q N <br /> rr o-5� N'"c'2 K SlOec�-.fin C:I�(1-v-_.P `� 00. �T"l <br /> -t o kko :enc w ax, Nf-,A4 No s, ,ovx Q a y Arec-s a�- Coh n S'Y1 <br /> Sze 2, <br /> Inspection Form Included: Q <br /> Comments Included: • , <br /> _ Business Rep's Signature Phone Number Insp_e or's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � NJ E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />