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Waste Tire S -ey & Inspection Repor' 'nspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1176674 <br /> CalRecycle t81(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 Inspection Type(Fill one) <br /> Site Suffix: 3 b r b 0 If 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: QIV7 tit 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> S--uV_i" Di�+r7 c,4 <br /> Physical Address <br /> Inspection Date � � / Z_ <br /> &�c=V-+�y` Cd-� f sZc� 2 I <br /> Time In Time Out <br /> Business Rep Title ® AM _ ® AM <br /> �y �p 3 U QPM ! j Z 5 0 P <br /> C14 - -` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) v !� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' V 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> rpC Latitude - - - _—_-_- -- -- 0_Hauter Indoor <br /> p 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet (D Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> - — —- -- — -—— 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTj N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 1 O 1 Other:§ _ <br /> Comments <br /> Inspection Form Included: 0 Le'fs'$-- O 2 3 <br /> Comments Included: ® <br /> Business p's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/) EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE <br />