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0 Waste Tire Su. Bey & Inspection Report 'Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 161(Rev.10/10) Survey Fortes - Page 1 I 1 - 1210297 <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: t ___) 50 6 __? Q l O Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC - If Referral,choose referral type(Fill one) <br /> Identifier: -�cU�l �G�GI�"�1 qu� Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> }� Inspection Date / g- <br /> Time In Time Out <br /> Business Rep Title ®AM ®AM <br /> l�✓ <br /> / 0 00 O PM < < Z 0 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ' 1 Q1 Active 0 Passenger Q Generator ®Outdoor <br /> C 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o 0 Inactive S Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ®Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 ® 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 /> O 0 - *Notice Of Violation 0 Extension <br /> 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 / q1_]j <br /> / N <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 EXE N <br /> a <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 0 In Compliance-No Violations o <br /> 0 0 Other:§ _ z <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included:® 6� —— <br /> Business Rep's Signature Pho Number 1.s e tor's ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �0 EXAM E 1112113 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />