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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1255848 <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 ProfileInspection Details <br /> TPID- 7 9 ,� _ 0 Inspection Type(Fill one) <br /> Site Suffix: I. Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �ck Y �i1 �`� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r� Inspected By q Inspector <br /> Physical Address G <br /> CA Inspection Date / <br /> S� o �� ��r �SZIS <br /> Time In Time Out <br /> Business Rep Title 40 AM AM <br /> � r \ _ I () ' S0OPM 0P Tc \�� [� <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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0_Closed 0 Alter 1v(,� A/A <br /> CaP� Latitude N 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Trud� <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> . ` \ z <br /> Comments�o .aC-��0-yk "Vic <br /> G Cr�5 e Calnce�'►rl. <br /> Inspection Form Included: 0 n f� f <br /> O 2a u6g—�Z � <br /> Comments Included: <br /> ess Rep's/ign Phone Number Inspec is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrect: Incorrect: EXAMPLEj 1112T3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />