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Waste Tire Survey & Inspection Report•Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1177529 <br /> ry <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- � 0 � � 0 Inspection Type(Fill one) <br /> Site Suffix: J Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: �) (� Q''A_/1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V,' I Inspected By Inspector <br /> Phys) a dd ess � l C j 6o U <br /> C6 (N Inspection Date / , 3 <br /> Time In J Time Out <br /> Business Rep Title l O AM O AM <br /> \ I a ' ! S 0 PM 0 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 /> T <br /> D 10 Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder i Other P. m <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 m / m / m <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 o <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 /> IS In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �\ 1 N <br /> o w% s I 1 On <br /> 40 ) J-' S <br /> - n_Qre'd -_ <br /> Inspection Form Included: Q 0(, <br /> Comments Included:® <br /> Business Rep's Si46fure Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: M � g E X A M E 2:N3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink <br />