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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of cle 181(R I 1 - 1210557 <br /> CalRecycle 781(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> A-Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: (D Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C_ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date e <br /> Time In Time Out r <br /> Business Rep Title i)AM ® AM <br /> � 1 T C; `� a 0P � L � J OPM <br /> 6 ` ��` ` - � C61^91-1— 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 /> Q Active Q Passenger Generator Q Outdoor <br /> Latitude O ® Closed Q Altered All <br /> GPS Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> P-Riness Type(Fill all that apply) 1 To-c— <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet p Government Q Retreader p Dismantler p Tire Derived Fuel <br /> U Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber /J <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (0 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 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 /> QQ 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 Ex7) 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 /> 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 ,f <br /> MA�+,�, l � � r1 - a .(1-av t ta„ -tl [�' �.�. <br /> ' �, P I r -1-tM hl C7TzJJ.' cm r- X71 t/� ^tip e�� �-tr'_ <br /> i _y� <br /> Ate,-3e i f�('n/W" a..'i" �i S 1'Z'c�"� 2�!Y!�'L' 101 Z—+- a 4v -� •--� <br /> .1- <br /> �,vr wrz -3 i -..�( <br /> Inspection Form Included: Q �G cics�Cv - <br /> Comments Included: Q <br /> Business Rep's Signat re Phone Number I e o Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: g E X A M P L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop Y. <br /> ® ■ <br />