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Waste Tire Ivey & Inspection Repor, Inspection Report Number <br /> State of California <br /> CalRecycle I 1 -1176733 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey_ — - -- - --- — BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ® Routine � Re-ins Re-inspection <br /> 0 Referral 0 Observation <br /> Local If Referral,choose referral <br /> Identifier: S�� �Q(,L V��!\ Co L(,(�� type(Fill one) <br /> 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> M A V C& h5��i T sZc�- 3 <br /> Physical Address l �S c& <br /> � Inspection Date / 0 LIPC, s33o 5 <br /> Time In Time Out <br /> Business Rep Title 0 AM ?, 0 AM <br /> O 0 PM `' Q PM <br /> - --- --- — --- - - — Operational Status i Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) U (Fill one only) (Fill all that apply) (Fill all that apply) ! (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator Outdoor <br /> - O <br /> Latitude 0 Closed 0 Altered <br /> GPS 0 Hauler ® Indoor <br /> C 0 Inactive 0 Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) 1 <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 0 Other P6101:--I <br /> PartB - <br /> 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 The Hauler Registration and Transport of Tires Q Notice Of Violation 0 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 Datem / / <br /> m m <br /> 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 EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 10 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 W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Other:§ <br /> z <br /> Comments <br /> ajow 0- <br /> CIA �1 <br /> Inspection Form Included: 0' <br /> �LD4t <br /> '"- <br /> Comments Included: <br /> Business Rep's Signature Phone Number lnspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct 46 Incorrect: (X 4� �] E X A M P L E 62081 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />