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Waste Tire Survey & Inspection Report Inspection Report Number <br /> calRecycle State of California 11 - 1210576 <br /> CalRecycle 181(Rev.y N0) 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: 6 b ! j v L © t 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �� i `��'l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �l Iyer-�`s ���j `T►i�-�� <br /> Physical Address <br /> 2 1 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> l ' 3 ® PM .2- ® 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 /> ® Active Q Passenger OF Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned OTR ® End-Use ® Container <br /> Business Type(Fill all that apply) <br /> 11* New Tire Dealer Q 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 d 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 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 /> ,6- N <br /> Inspection Form Included: <br /> Comments Included: '' <br /> Business Rep's Signature Phone Number p c 's gnature Phone Number <br /> INSTRUCTIONSON BACK Correct: Incorrect: E X AVpyr: A <br /> E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C ® ■ <br />