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Waste Tire Sdw & Inspection Re orLe4ection Report Number <br /> CalRecycle State of California y _ <br /> CalRecycle 181(Rev.y(Co) Survey Form Page 1 11 1242398 <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: Q Routine a Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: So�cb�� Covh h.� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address — r I ►Q,rv►�L <br /> Inspection Date 4q <br /> �( <br /> Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> P" <br /> 1 � CW PM � ' U � 40 PM <br /> C.�1nc� 5111�-L rk. �`'�.���"3 - <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 /> -50 ® Active Q Passenger a Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned I. ® OTR End-Use ® 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility v ENFORCEMENT STATUS <br /> T�i� l <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 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q `Lm4 �q �$ <br /> Comments Included: ® ` � -y6a- 6� <br /> Business p's Signature Phone Number I s$ect 's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I, Incorrect: _ 4 � E A P L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CopyYL <br /> ® ■ <br />