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Waste Tire Su. Jey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196697 <br /> CalRecycle 181(Rev.y(Ca), 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- '2— <br /> ^ - O � Inspection Type(Fill one) <br /> Site Suffix: 1 L 1 L ID Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V��,l� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical ddWss' <br /> e&I `�SZyo Inspection Date <br /> � C� <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ' O * PM O • PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(VI/hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger • Generator Q Outdoor <br /> D Q Closed Q Altered N <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 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 /> 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 /> Q Q 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 ,In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ��/ <br /> Business p's Sig ture Phone Number Ins pec or's§ignature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: NJ jEjXjA�MjPjLjEj 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />