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Waste Tire Su. Bey & Inspection Reporielnspection Report Number <br /> CalRecycle State of California I 1 - 1242075 <br /> CalRecycle 181(Rev.y(CalRecycle) <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 /> Site Suffix: l &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 7Q �oov �V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r (( <br /> Physical AdcWessS © <br /> Inspection Date <br /> K-1(-���1 CAS 53 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 2S I PM � - IMP <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active & Passenger • Generator •Outdoor <br /> O Q Closed Q Altered <br /> GP� 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 <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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 <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 <br /> In Compliance-No Violations o <br /> Q 1 Q Other: <br /> Comments <br /> y`ox Luio-fS N� <br /> Inspection Form Included: Q <br /> Comments Included: T'Ii <br /> slness4Rep'satu-re Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ® � IEIXIAIMIPILIEI 1112 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />