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Waste Tire Survey & Inspection Report inspection Report Number <br /> Cal Recycle State of California <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 I 1 - 1176620 <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: 3 t �j t{ Q n <br /> - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r, If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J3 Inspected By Inspector <br /> �'V�r'G- � rvC�l►�� <br /> Physical Address <br /> 12 7 1 S7 Ln- <br /> Inspection Date © 8 <br /> S�cutw� GA R s !s <br /> Time In Time Out <br /> Business Rep Title ® AM AM <br /> •3vfk't'- 1 f • 1 `� ,0 PM S 0 PM <br /> FVD 1lGn-C�. 0),SP�"w1r - - -- - -- <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 /> ® Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 O Closed Q Altered <br /> Q Hauler 0 Indoor <br /> O Q Inactive Truck <br /> Longitude • <br /> A Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fil4,all thatapply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader <br /> 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 /> O 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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> O a° :14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> d Q 14 CCR 5 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> O O 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 /> O 0 Other:§ In Compliance-No Violations <br /> _---- <br /> Commems — - - - <br /> e Va-S 1402 cd <br /> Inspection Form Included; Q <br /> Comments Included: ® 61 <br /> C2oq L'f62r OroZ <br /> Busines ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: /j � EXAMPLE 1 2 3 62081 <br /> —-- <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />