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Waste Tire S rey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1176587 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: —i-00P-411 <br /> /,�-„yam, 61Jy;-✓L,(� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namf� v Inspected By Inspector <br /> �GECL. /TUU i 1Ly / etjl ,Ci1,1-S <br /> Physical Addfess ✓ (J / �!-3c �7- <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> / 0 PM f a y ® PM <br /> �GCGl�G c�GCi' GL'U �fG��� — <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 B Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 Other <br /> G�a <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting RequirementsI Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle m m m N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations � <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> r no/�ccl ' - - <br /> Inspection Form Included: Q x <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:A Incorrect. ' + �i E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C py: <br />