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Waste Tire SCey & Inspection Repo: Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1226390 <br /> CalRecycle 181(Rev. H0) Survey Form - Page 1 <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: C g Q ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C_ � J v�� If Referral,choose referral type(Fill one) <br /> Identifier. Cit 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressI C <br /> N - Cen 1 <br /> A-ve.- Inspection Date <br /> 376 Time In Time Out <br /> Business Rep Title 0 AM <br /> } 0 AM 0 <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 ® Generator ® Outdoor <br /> p <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude0- Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> a New Tire Dealer ® 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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> O 1 0 Other:§ -_.--. <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business iGpItWhature Phone Number fKape, is S' nat a Phone Number <br /> INSTRUCTIONS ON BACK f Correct: Incorrect:- E AMP 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Ce <br />