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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1245243 <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- ` Inspection Type(Fill one) <br /> Site Suffix: 1 3 s g & Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: V� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> )ze1 f l <br /> Physical Addressty \ w 3 1 0 <br /> 5o SCO CY\� a <br /> �-o C)K-�U v\ Inspection Date g / 2, <br /> 2 Time In Time Out <br /> Business Rep Title � 1 C O AM F O AM <br /> yI Oe.l �� SOW 7 PM ?j QPM <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 /> i Active Q Passenger '& Generator 0 Outdoor(7 <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor l <br /> O Q Inactive *Truck <br /> Longitude - O Planned Q OTR 0 End-Use • Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle � <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q 0 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 Q Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Other:§ <br /> Comments <br /> COM <br /> Vt a 10'0V_\Ce✓\ <br /> Inspection Form Included: <br /> p <br /> Comments Included: - <br /> 4ines—s-Rep's Si 'ature Phone Number In4peb,'s ignature Phone Number <br /> INSTRUCTIONS ON BACK FCoWect--* Incorrect: EjX�AjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />