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Waste T0fO a vey & Inspection Rep" Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1245393 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Rage 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- Z Inspection Type(Fill one) <br /> Site Suffix: 1 t,' I I I ( I&.Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: U t l,1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> TViG�c� .� Sv I v-f;c�c i��S- ►;��S) 3 �7 _ 1 © 1t,;Jo„ Lt,�ff <br /> Physical Address <br /> Inspection Date V <br /> U Time In Time Out <br /> Business Rep Title AM I 5- 0 *AM <br /> I I 0P l 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count hol /PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (/ 0 Active 0 Passenger 0 Generator 16 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 /> 0 New Tire Dealer 0 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 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 /> Q Notice Of Violation � Extension <br /> Q Q <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / Ffl <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 EJC7) 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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 <br /> 04 C <br /> Inspection Form Included: Q - GG <br /> 4� <br /> Comments Included: <br /> Busine R ignature Pho a umber nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect: EXAMPLE 12 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />