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Waste Tire ;,drvey & Inspection Repo 4. Inspection Report Number <br /> CalRecycle State of cle181 California T 1 _ 1- 1- 7674. 0 <br /> - 1- 7 6 7 /y. 0 <br /> CalRecycle 181 Recovery <br /> Survey Form - Page 1 1 �a 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- , 2 q t'! '1 a _ Al Inspection Type(Fill one) <br /> Site Suffix: J L '1 lJ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: ��� J �U�U, CoU,r� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1�v1�o e� ,l���. 1 O <br /> Physical Address,ss <br /> CA_ 1 � Inspection Date q <br /> / Time In Time Out <br /> Business Rep Title + 7 O AM / ) O AM <br /> 1 v` ( 5 ® PM I �/ PM <br /> 0 Lu_rl� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a � � 3 <br /> Active ® Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 Vj Lt. <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 Q Extension <br /> Q Q 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 / m / m N <br /> 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 EXE N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> i'�4� f151�J` UW N D V� I <br /> L <br /> k) C4 t �j -' <br /> S'2� Cvccl ccv A Foi,n <br /> Inspection FormIncluded: Q <br /> 63 Fj5*'-- <br /> Comments Included: <br /> &esjep�'sqSIgr+tyr_ce Phone Number Inspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPL E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />