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0 Waste Tire S,..vey & Inspection Repor, Inspection Report Number <br /> Cal Recycle state of California _ l 'j ® C <br /> CalRecycle 181(Reu10/1 0)y(Cal Survey Form - Page 1 / (, <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> ,D- ` / (� Inspection Type(Fill one) <br /> Site Suffix: 1 1p > 1 I S Q ( .Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: S CLO -jo A y�,I u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I 1 Inspected By Inspector <br /> Physic4il Address <br /> J�n <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ^ AM O AM <br /> UI 5 O PM 0 ® PM <br /> U,L� ����k on ��rlcr -- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /7( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> o ® Closed Q Altered r� lA rVA <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck JA <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 ® Other 2':�'1ULoC0_ <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 <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 EXE 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 /> f <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 Q1 Other:§ <br /> CommentsCA e, aria <br /> v �yD4u r <br /> lection Form Included: Q . Ay 'l <br /> Comments Included: V <br /> Business Rep's Signature Phone Number Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: C X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />