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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210444 <br /> CalRecycle 181(Rev.y H0)Recycle) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- g � � 1 � � � m Q � Inspection Type(Fill one) <br /> Site Suffix: f 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: <br /> S�/1 \ Q �1^ - Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> �1As <br /> Physical Addre1s�,s J 1 CS Cb—CT 0 <br /> Inspection Date g / 1 <br /> Time In Time Out <br /> Business Rep\_ Title C 0 AM O AM <br /> `� SPM � u � �1 PM <br /> /Vr <br /> L <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I 1 1 ! (Fill one only) (Fill all that apply) (Fill all that apply) (FII all that apply) <br /> "r V 10 Active A Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS 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 ((r'UQlp�`�� <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXn <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 /> Lu <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 ILAMASt -�l'l 1 R2(� '(Y1 �i (),In, 1JI An <br /> No MQA a ' )an& _U cAr.cS n(urn <br /> Inspection Form Included: Q 8 <br /> Comments Included: ® ' <br /> Bu iness Rep's nature __ Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �0 EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />