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Waste Tire Su. ✓ey & Inspection Report 4nspection Report Number ■ <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.y(CO) Survey Form - Page 1 11 1196466 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ 3 2 O Inspection Type(Fill one) <br /> Site Suffix: I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: q � V� Q Educational Visit Q OtheryG�� 5aa � <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address , / ►��T v <br /> °15-c>,A S, \Acx_0ooA V-& . <br /> CAS °1523 Inspection Date <br /> ��ev,�-�\ Cc�v►�e <br /> Time In Time Out <br /> Business Rep Title 7 / O AM O AM <br /> S L ' V 0 PM * 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 Q Passenger 0 Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 0 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 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 Q Other:§ <br /> Comments,�n`�� CL�� ' \►�G�'�d -��'C'P '1���PeC'C`�� ���'e�� \y`�S N <br /> r vlCecv\ <br /> Inspection Form Included: Q ZQ(�9Z!5'J$2j <br /> �Q J �Z 0u <br /> Comments Included: ` q a t <br /> Business Rep's Signature Phone Numbernspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />