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, <br /> Waste Tire S11. vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.Resourcesy(Cal Survey Form - Page 1 T1 - 1196517 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' � � � n � � _ O i Inspection Type(Fill one) <br /> Site Suffix: ` 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �av� ,�� y�� � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> C i C oafs ��•C G 1 1 <br /> Physical Address 1 0 <br /> $303 - <br /> S2. Inspection Date <br /> Time In Time Out � <br /> Business Rep Title 0 AM So 0 AM <br /> O O 0 PM PM <br /> - -- -- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Z S <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> 0 Active Q Passenger S Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler I* Indoor <br /> O Q Inactive 40 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 0 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 /> Q Q <br /> 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 /> Q Q 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 N <br /> Q Q 1,4 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 /> - — -- z <br /> Comment�\p`,.�wG\ <br /> V,)E���c7 :vnnS oc cera-SC:52' .eC� <br /> Inspection Form Included: Q <br /> Comments Included: 0 �J <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: XC ® q IEIXIAIMIPILIEI 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />