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Waste Tire Su. rey & Inspection Report <br /> }Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1196458 <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- , � t� f7 � � 2 _ O 1� Inspection Type(Fill one) <br /> Site Suffix: —1 7� J *Routine Q Re-inspection Q Referral Q Observation <br /> Local +� ` If Referral,choose referral type(Fill one) <br /> Identifier: sQ� V dowaV%� Cov�h..' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ,7 Inspected By Inspector <br /> _ � � � v <br /> Physical Address m ATT <br /> Inspection Date <br /> S ���ov1 C� gs21 S <br /> Time In Time Out <br /> Business Rep Title C� AM AM <br /> Q PM 1 O ® 0 PM <br /> e7OA ?20 �CkS`O`��^ O���� 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 /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive I♦ 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 l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other ` kms& la,Cse\ <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 a <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 <br /> In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments,s�_` <br /> - <br /> Inspection Form Included: Q c <br /> Comments Included: <br /> Business Rep's ignature Phone Num r Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect- IEXAMPLEI 1112L3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />