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. . <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177616 <br /> CalRecycle 181(Rev.y 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- I q / _ C Inspection Type(Fill one) <br /> Site Suffix: U -a 6 (1 #Routine Q Re-inspection Q Referral 0 Observation <br /> Local C - _ ` If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date / / I 3 <br /> CA x(5336 <br /> Time In Time Out <br /> Business Rep Title ®AM Q AM <br /> I 1 • S C? 0 PM f ® PM <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 (OP Passenger 0 Generator ® Outdoor <br /> GPS Latitude O0 Closed Altered O Hauler ® Indoor <br /> O O Inactive Q Truck <br /> Longitude - <br /> • Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 4) New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers' Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Z <br /> ®In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> u <br /> Inspection Form Included: Q a n <br /> Comments Included: ®- - C� � a! .�Go y6�`�6 <br /> Cu ss Rep's Signature Phone Number nsp t 's ign ture Phone Number <br /> INSTRUCTIONS ON K Correct: Incorrect: E X A L 1 (2 3 I 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co ■ <br />