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Waste Tire Sul <br /> Vey & Inspection Re <br /> or"spection Report Number <br /> State of CaliforniaCaliforniaCalRec <br /> CalRecycle <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 11 - 1176419 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q , Inspection Type(Fill one) <br /> Site Suffix: (p 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SC"" O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> Kar �A-t�.�-o r► c4i v� Ryc, r © J � <br /> Physical Address ( J ((�� �� ��I•��+�� <br /> Inspection Date O <br /> (rA qS 33� <br /> Time In Time Out <br /> Business Rep Title /' S O AM ` d 0 AM <br /> 41 <br /> D / Q PM CJ Z o 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 ® Passenger ® Generator ® Outdoor <br /> Latitude 0 Closed 0 Altered <br /> - — 8 Hauler <br /> 0 Q Inactive Q Truck <br /> Longitude — 0 Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 EXE <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities Lu <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ -� <br /> Comments 4 <br /> !A 14-C <br /> Inspection Form Included: Q <br /> Comments Included: `20.4��—��$—04-'Z- <br /> Business <br /> Business Re s Signature Phone Number Inspector's Signature Phone Number <br /> - -- <br /> INSTRUCTIONS ON BACK I Correct Incorrect: E X A M L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L LE <br />