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l+i/S.GiO'v'S «fid <br /> 1 � <br /> Waste Tire Sup vey & Inspection Report f Inspection Report Number . <br /> CalRecycle State of California I 1 - 1226211 <br /> CalRecycle 181(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: ( Lt y 3 0 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local v1 CQ, If Referral,choose referral type(Fill one) <br /> Identifier: //�4(yQ CHP Q CalRecycle Q Complaint <br /> Q Educational Visit Other <br /> Business or Facility Name Inspected By Inspector <br /> Physica-f Address �j G 1 7 ,•- <br /> �� <br /> Inspection Date / C-) —; <br /> L��c 1. �!S z Y O <br /> Time In Time Out <br /> Business Rep Title D r j U ®AM O D 6 Q AM <br /> ® PM <br /> �uGrr."�(' s��r►clovccl7 .��s: ,r <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 /> Active <br /> ® Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> 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 /> ® 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / FFI / 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 EX7) 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 un f V \ <br /> ( o /7 <br /> —L-I&r �v tcc J <br /> Inspection Form Included: Q <br /> Comments Included: (�- ��b'2 f/- � — ./ `z,�j��6 <br /> Busin s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> Correct: incorrect: N� ' E X A M P I L(EI 1112 3 62081 <br /> INSTRUCTIONS ON BACK � <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />