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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177963 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form o Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V � Y�i �6� <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 O Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> q(' <br /> Identifier: 5 )��j �� ,� (/_"0 A'4tA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> 1 <br /> Physical Address <br /> Inspection Date 7 /1 1 3 <br /> Time In Time Out <br /> J 11 <br /> Business Re I Title ^� O AM O AM <br /> 1, f�� Vii n 5G111(/�� (�cl(J'� SDl\ eC ® PM � �J ® PM <br /> NO S U O A, nLO net 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 ® Passenger ® Generator Q 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 ® Container <br /> Business Type(Fill all that apply) <br /> ® 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 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) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 Other:§ <br /> t I <br /> Comments' <br /> Inspection Form Included: QVJ4 <br /> ' <br /> Comments Included: <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X W �j E X A M P E l 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy�4�: ® E <br />