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-- -- ------- --- -- --- --- - <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle State of California 11 - 1230399 <br /> CalRecycle 181(Rev. (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- Inspection Type(Fill one) <br /> � 14 � � � O � <br /> Site Suffix: I 0 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: a v% � \ OCHP OCalRecycle Complaint OEducational Visit OOther <br /> Business or Facility Name Inspected By Inspector <br /> D'B lA geoec�� s hoc " 3 q - 101 MATT U <br /> Physical Address <br /> S CA C,�^S'M Inspection Date 0 Ct / 1 9 ) <br /> Time In Time Out l <br /> Business \ Title 1 AM 0 AM <br /> % 'V� O PM O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2j <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> i Active IID Passenger 0 Generator O Outdoor <br /> O Closed O Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> O O Inactive • Truck <br /> Longitude – O Planned O OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder 0 Other llvskAk)k�'Zh Cente_r- <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 O PR - O Notice Of Violation O Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> ui <br /> w <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> O O Other:§ <br /> CWomCmdesntsY1 o�T.9.�` <br /> GILL Q 'QyA 0wZ `CO 5 k <br /> Inspection Form Included: O � a'jc_4g00 <br /> Comments IncludedBuR �� Z –M — <br /> Phone Number Inspect is S gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � g EXAMPLE 112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />