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Waste Tire Survey & InspecU 0 n Report Inspection Report Number <br /> CalRecycle State of California I 1 — 1242303 <br /> CalRecycle 181(Rev.y H0) Survey Form - Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n Inspection Type(Fill one) <br /> Site Suffix: I ` 5 3 q - ® 1 <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local �. If Referral,choose referral type(Fill one) <br /> Identifier. Sin JO Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> _1 <br /> Business or Facility Name Inspected By Inspector <br /> fl � �ep�; r d-T�c� 3 q - l 'b co- � <br /> Physical Addr ss <br /> n <br /> Inspection Date I / O 1 / I <br /> Time In Time Out <br /> Business Rep Title ' I B AM 16 AM <br /> 1 <br /> K,k 1 W�,41 Slr`�1i�1 1 b ar Cr O —1 S 0 PM I 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger 0 Generator I*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 • 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 /> 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 <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 /> 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 1 Q 1 Other:§ <br /> Comments <br /> Inspection Form �ncluded: ol r \`.1 / O )-a j1 �Comments ncluded: A l `�" ' <br /> Business Rep's Signature Phone Number Inspe t is Signature Phone Number <br /> X <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A 11 M L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® 0 <br />