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Waste Tire Sup ,iey & Inspection Report nspection Report Number ■ <br /> CalRecycle State of California 11 - 1177761 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey ,BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ Q 1 Inspection Type(Fill one) <br /> O <br /> Site Suffix: l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r-- If Referral,choose referral type(Fill one) <br /> Identifier: �� 3Onn I,T'� Co V Y\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> r ` <br /> Business or Facility Name ,, C Inspected By Inspector <br /> �c�•In .oda v�,� �vv�.�7 •C�� l�la�►,�eran�2 + <br /> Physical Address / q - /'a ` TT v <br /> 1�t o 9, z�1�,� a-\j e. <br /> CC�1/� ZC�5 <br /> S� <br /> ` ` p d Inspection Date s / © � / 1 3 O � 1 -1S <br /> Time In Time Out <br /> Business\Rep Tittle` ( C) AM 1 O AM <br /> �G l!� ��`f� /�tAW��Y� �ro�• 1 � PM � 2 I � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) u S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 40 Active 0 Passenger 0 Generator 41 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive 41 Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 0 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 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 <br /> a <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 E)C7) N <br /> Q Q 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 u, <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 /> WcL-S ',n cAle4 � <br /> �d �y�o�ja��—oY\S---aC 1- vemS 0`— ►SCP ('�n <br /> Inspection Form Included: Q_ /�Comments Included: <br /> Business Res Si n t re Phone Number Insp nature Zdq� Phone Number <br /> INSTRUCTIONS ON BACK Correct:* In orrect: M � N E X A M P L E j 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />