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Waste Tire Sevvey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California I 1 - <br /> CalRecycle 181(Rev. 1186146 <br /> (CalRecycle) Survey <br /> Survey Form a 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- 1 a - Inspection Type(Fill one) <br /> Site Suffix: �� D 3 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address o 0 ✓Q <br /> zoo 5 Gke"-o <br /> G Inspection Date <br /> Time In Time Out <br /> Business Rep n Title Q AM Q AM <br /> O PM QPM <br /> C - 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/PTP) <br /> e Active 0 Passenger 0 Generator 0 Outdoor15 <br /> - O <br /> GPS Latitude 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> 0 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container`10 <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A THAULING-AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 * 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 16 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ ° <br /> Comments T/_T 10 1^110 l1;'., <br /> Q'•' �'(, i !. iil!� jj�..tt, )dyL �/✓/'�2g/✓ <br /> Inspection FormIncluded: <br /> Comments Included: �70Q - }2 �` `l'" 3�j 145 i <br /> Business Rep's Signatu& ibti6nehumber Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 77*:7 EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />