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Waste Tire S6. iey & Inspection Report Jnspect►on Report ,,:umber <br /> CalRecycle State of cle 181(R I 1 - 1196472 <br /> CalRecycle181(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- inspection Type(Fill one) <br /> Site Suffix: 1 S 493 3 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: 1Y\ pad V;� � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 (�\ // Inspected By Inspector <br /> k�n Ad ress l <br /> MATT",) <br /> I Inspection Date Q / l / 1 3 <br /> Time In Time Out <br /> Business Rep \ — Title 0 * AM 1 � � AM <br /> �l v O PM , O PM <br /> Cti•riS ��, awn <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole PTE Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 40 Passenger ! Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 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 /> 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 49 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 <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 <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 /> a <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 /> Lu <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 *in Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> Inspection Form Included: Q n0f— <br /> Comments Included: 4 •[ <br /> usiness Rep's Sig a re Phone Number 14?p�eSignature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X t IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />