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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196599 <br /> ry <br /> CalRecycle 181 (Cai 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- � � S , 1 - O ' Inspection Type(Fill one) <br /> Site Suffix: "� • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � �v;V\ CoQ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 12 A eS� TcvClt�v\C `�'inc. 3 1 - 1 0 � NIS T TU <br /> Physical Address oC <br /> 00 Y-1 <br /> 952%.AC) Inspection Date , 2- <br /> Time In Time Out <br /> Business Rep Title 1 2 S O AM Z S 0 AM <br /> 0 PM 0 PM <br /> U-�Zw\h ?C►�11 1M,Y� � Sv V�SC9� <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 /> •Active 9 Passenger &Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned * OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Z <br /> Q New Tire Dealer Q Auto Repair 16 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 /> 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 M-3 <br /> / gM� � <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 EX7) 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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *Inrmpliance-No Violations <br /> Q Q Other:§ <br /> Comments <br /> "C�. `DC7� \��.lSt�S �f� \• <br /> Inspection Form Included.. Q <br /> 3280 <br /> Comments Included: . <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: NJ E X A M P L E 1 62081 2 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />