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Waste Tire S91ey & Inspection Reporbinspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245215 <br /> CalRecycle 181(Rev. (Cal 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: ' 3 2- 71 © 1 `Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �� 1-1 <br /> V oajV 1n O CHP Q CalRecycle O Complaint Q Educational Visit O Other <br /> Business or Facility NeV Inspected By Inspector <br /> Physical Address M <br /> C Inspection Date <br /> t J Time In CJ Time Out <br /> Business Rep Title U O AM O AM <br /> 1 � doPM / v t* PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill altthat apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active Q Passenger . Generator 9 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive *Truck <br /> Longitude — Q Planned Q OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ! 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 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 In Compliance-No Violations o <br /> O O Other:§ <br /> Comments O .�j [t 0.\ _ a ` <br /> Inspection Form Included: 0 C _ c <br /> Comments Included: — <br /> uses ep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS BA �Correct' ncorrect: NK & g EXAM P E 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy <br /> LE4 <br />