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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of cle 181(R I 1 - 1244915 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page I <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: ®Routine QRe-inspection Q Referral <br /> Observation <br /> LocalV If Referral;choose referral type(Fill one) <br /> Identifier: Ck�'Jo 01 to I r1 �t�n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> E. <br /> Inspection Date � / l 9 <br /> 11 J Time In Time Out <br /> Business Rep Title 1 O AM O AM <br /> ' 1 0 PM 'ZI, Q 8 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude <br /> O ® Closed Q ARe�lre /�jjq Q H9u,/A Q Inddb�] <br /> /A <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> 0 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 Q - Q Notice Of Violation Q Extension <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 /> 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 /> a <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 /> in Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments iJI'*-11-41 J- <br /> 11J�,� nc7�'c�1= N� -V�oLw�'U� b1 a1c��_Q'�_Cpl1C_a.rf� • <br /> IM <br /> Inspection Form Included: Q ^� <br /> Comments Included: Q k E/ n 6� i)o <br /> Business Rep's Signature Phone Number Inspe is Signature 114hone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: :X� [EIXIAIMIPILIEI 11123 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />