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0 Waste Tire Su ,iey & Inspection Report Inspection Report Number <br /> CalRecycle State c cle11California I1. - 12 2 9 9 7 7 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- -2- / � � - O t Inspection Type(Fill one) <br /> Site Suffix: o I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local5w, <br /> If Referral,choose referral type(Fill one) <br /> Identifier: �10 b v ^ co Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y <br /> Inspected By Inspector <br /> Physical Address O ' 1 <br /> n^ 9 5337 Inspection Date 03 / 04 <br /> Time In Time Out <br /> Business Rep Title 0 AM 2 *AM <br /> C 1 V Q PM u O PM <br /> Cat 1; r� �e1.to� Se�c� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I \ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger 46 Generator 0 Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O O Inactive I* Truck <br /> Longitude - 0 Planned 0 OTR O 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 <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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *in Compliance-No Violations o <br /> Other:§ <br /> Comments �bv �'��ir�'�tOy� �V\,P am <br /> C)� L7V�2f`I� <br /> Inspection Form Included: Q _ _ <br /> Comments Included: ��`� <br /> Business Rep s Signature Phone Number Inspec is ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />