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{;1i,7.::.c,:-s}:.,..:•..-fa ar n-._ .. .. ,.,.........�..,,.:e� 'c.•.�.:..sw c.critf�.. .,. ... .., c:........::W:.............. _......_�_a..r.r........_.s e ......._........v.........1_..�_.. _ .. <br /> Waste Tire Su,vey & Inspection Report (inspection Report Number <br /> CalRecycle State of California 11 - 1226584 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Busin ss Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: ( 5 O L C1 O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local, l If Referral,choose referral type(Fill one) <br /> Identifier: Sark ����� � �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physi Dal Address r <br /> Inspection Date } 0 1/ 3 / 1 <br /> C <br /> A ��'��� Time In L Timle Out <br /> Business Rep Title 0 AM 0 AM <br /> G -0 PM (a PM <br /> -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tir�Count(VI/hole/PTE) <br /> 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® 0 <br /> w <br /> Active Q Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler ® Indoor <br /> O Q Inactive (a Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Busi es s Type(Fill all that apply) <br /> Q N w Tire Dealer Q Auto Repair ® 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 <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 /> Q <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q g 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q (b 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> f <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 Q Other:§ <br /> Comments <br /> O> <br /> Inspection Form Included: Q <br /> Comments Included: 01 // -— <br /> uee6p <br /> ignata Phone Number Os—pt i ure Phone Number <br /> 62081 <br /> INSTRUCTIONS O BACK �Correct:o Incorrect: E X M L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co L ® ■ <br />