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Waste Tire Su. vey & Inspection Repon Inspection Report Number ■ <br /> CalRecycle State of cle 181(R I 1 - 1210 510 <br /> CalRecycle 181(Rev.y(Cal 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: �j '9 Routine Q Re-inspection Q Referral Q Observation <br /> Local �' 1 If Referral,choose referral type(Fill one) <br /> Identifier: Stn 1�p�j 1ki(� ���n ll� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected By Inspector <br /> L� CU�n,nb W�ec�S ��1'ce5 _ <br /> Physical Address <br /> � CC l JW'T r 0 <br /> -D ^ �SZoS Inspection Date p <br /> Time In Time Out <br /> Business Rep Title O AM L� O AM <br /> ' � V QPM � ` � ® PM <br /> U 1 U �� - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q t p t_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "1 �D ® Active ® Passenger # Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> IS <br /> Q Q - Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> ® 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 Datet t / M) (0 <br /> / 1 3 <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 EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years W <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> I 1 � <br /> Comments �A <br /> C.4,4 C-, r 1 ItS <br /> J0'r, <br /> Inspection Form Included: * _ <br /> Comments Included:® <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: FE FX rA MI L 111213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co zV <br /> ® 0 <br />