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Waste Tire S6. vey & Inspection Repor ,, Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10M)(Cal Survey Form Page 1 I1 2 4 216 <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: L ® Routine Q Re-inspection Q Referral Q Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: <CkVN, Of,�Gbv�1^ "J 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name CC Inspected By Inspector <br /> Physical Address L Q [ 06,q-nn <br /> o2©li,L{ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep \ Title ®AM O AM <br /> -t 1c��1�14�1GtU ���a',�.�1 Q.cN�✓ L � : LL O O PM Z t S ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) .? C_,> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (0 Active ® Passenger Generator ® Outdoor <br /> O <br /> GPS Latitude 0 Closed Q Altereci ® Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader U Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® 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 0 Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 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 EX7) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O p 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> (Din Compliance-No Violations o <br /> Q Other:§ <br /> Commentsself- <br /> ` <br /> L <br /> Inspection Form Included: 0 !62� <br /> Comments Included: 0 ~ .24*�l6 _� <br /> Business Rep's Signature Phone Number 1 pe tor's re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X[A 1 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />