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Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1177756 <br /> CalRecycle 187(Rev. (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- Inspection Type(Fill one) <br /> Site Suffix: ` di Routine Q Re-inspection Q Referral Q Observation <br /> Local {, If Referral,choose referral type(Fill one) <br /> Identifier: 111 ��cx�tc�.w� C�^'L 1�/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 111 Inspected By Inspector <br /> Physical)A1\ res r <br /> 1 1 U ! /1 <br /> �j Inspection Date O / O <br /> � l 5�i 2 Time In Time Out [ <br /> Business Rep Title i - ®AM 0 AM <br /> 1 1 5— © O PM l � � I� ® PM <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 /> G '-'-1 <br /> J0 Active ® Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 ® Other <br /> X4 <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 <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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <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 Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Re nature Phone Number ;Inspect is Sig tur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E A P t�E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C Py. <br /> A �� <br />