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0 0 Waste Tire Sukey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1242099 <br /> CalRecycle 161(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 O ` _ l..J l Inspection Type(Fill one) <br /> Site Suffix: b L ! Routine Q Re-inspection Q Referral Q Observation <br /> Local �+�7 If Referral,choose referral type(Fill one) <br /> Identifier: To /yV �y� l is Jy� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _"1 � Inspected By Inspector <br /> Physical Address <br /> X05 �asco"nc-e-NI <br /> Inspection Date C> S / <br /> Time In Time Out <br /> Business Rep Title ` l S O AM O AM <br /> el _ Z' S • PM WPM <br /> V <br /> h m_ ` Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) U \ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -1 y is Active Q Passenger 10 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive •Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair 0 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 /> 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 N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years a <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 /> CommentsAINR <br /> �Ob <br /> 011 <br /> Inspection Form Included: Q <br /> Comments Included: Pal <br /> �_� <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: I EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />