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Oa Waste Tire Su.vey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California 11 - 1177523 <br /> CalRecycle181(Rev.1Oil 0) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- q r _ - Inspection Type(Fill one) <br /> Site Suffix: ` c) ` S Q Routine Q Re-inspection Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Coln�U �U Cou,A n Q CHP ®CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In I Time Out <br /> Business Rep Title O AM O AM <br /> ® PM O ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> D ® Closed Q Altered <br /> GFS 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 /> 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 ®Other n„t,A^&_ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-RegistratiorVDecal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements I Date W m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle I I I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 Q JOther§ <br /> � l l _ <br /> Comments\S� Xcct�V4� t /�7' 1 �UI - U 1+ t <br /> � GtCi��V; K <br /> �� ,s�1_ 1 <br /> Uc� oo�(n <br /> in() -q"04 W's Uj U 'Cat 0"Iccrll_ <br /> S�kc is ces��tClce _ U�s� t�ss a� `� �i�'�. �y �•f�s c�tiSer,wl. ��se� 0, <br /> Inspection Form Included: Q 'p� <br /> Comments Included: Q -- - — - <; �V`� �"L� L�5 <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> -- �-�( — <br /> INSTRUCTIONS ON BACK Correct: Incorrect: WX W NJ EXAM L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ®62081 <br /> ■ <br />