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0 Waste Tire S►.. vey & Inspection Repork. Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1177962 <br /> CalRecycle 181(Rev.y(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- _ O ( Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: A 4S J 0 el I.A)/) (0 tA(1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name LL ` Inspected By Inspector <br /> Physical Address <br /> aC� E Icm�n� <br /> Inspection Date �j / 3 <br /> /LII Time In I Time Out �\ <br /> Business Rep Title l ® AM ® AM <br /> I1 Q Q PM Q PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ®Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler ® Indoor <br /> o Q Inactive ® 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 ® Other E 4;n �4r, X41 <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 Q Q Notice Of Violation Q Extension <br /> 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 / Ffl <br /> / 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 <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 /> Comments � 'I <br /> � -I / I <br /> G, c, rc, 1n5 bn o I *bI(IOU);r N <br /> No y��I�kl'v�s of, o ruA, ) <br /> Inspection Form Included: Q <br /> Comments Included:* <br /> B�lffne, a Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS NBA Correct: Incorrect: NJ E X A M P E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink&EA ® ■ <br />