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Waste Tire Su, iey & Inspection Report inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev. y(Ca), Survey Form - Page 1 I1 1196500 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / h / / - © Inspection Type(Fill one) <br /> Site Suffix: b V b b 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Yl 5�a V`r C V r"/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 6 / Inspected By Inspector <br /> Physical Address <br /> \'A00 v--, %';r�c'o <br /> _,Cacy C� 1 S� Inspection Date 3 <br /> II Time In Time Out <br /> Business Rep Title 1 , 2 D O PM C) O 0 PM <br /> 0 AM <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 /> 0 Active 0 Passenger As Generator 0 lO��,utd000r <br /> O 0 Closed 0 Altered N 1/` <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PR - 0 Notice Of Violation 0 Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orEXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments \ <br /> Inspection Form Included: 0 (�C7��BSS` 70 3 r �Phlone <br /> Comments Included: Business Rep's Signature Phone Number Inspector's Signature Number <br /> �-�( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X NJ E X A M P L E 1 62081 <br /> 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />