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Waste Tire Su. rey & Inspection Report Inspection Report Number ! <br /> State of California <br /> CalRecycle 11 - 1210 316 <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 /> Business Profile Inspection Details <br /> TPID- 1 0 g r _ Inspection Type(Fill one) <br /> Site Suffix: 7 01 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 'gcack e kke.5 8y `(`%hd 3 q - 1 0 1 _T_T v <br /> M <br /> Physical Address / �A <br /> Z1 NI a>n Sk. <br /> Inspection Date jo / � G / l <br /> Time In Time Out <br /> Business Rep TitleS 0 AM 0 AM <br /> L * PM ® PM <br /> F1o�2v►�;,no M�1e�ae2 C�he,� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /0 q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 'I ®Active * Passenger 0 Generator 0 Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q 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 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 EXELo <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ ` <br /> Comments <br /> �, \ �L.t!`'1�1�b.Q., t� S"tom 'C�'C' �1n�� \• �^ .,, <br /> V\ CQ w jkr O C 1n <br /> Inspection Form Included: 0 �� <br /> Comments Included: <br /> A ��GNi/ 209- 16$•'328'1 <br /> siness Rep's Signature Phone um er Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: 01) EXAMPLE 2 3 1 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />