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Waste Tire Su. ✓ey & Inspection Report- Inspection Report Number <br /> CalRecycle State of California T 1 — <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 1245075 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type(Fill one) <br /> Site Suffix: 15� 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ulm 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address �� C) IK,�cj p4f(Z <br /> Inspection Date / o / 5- <br /> Time <br /> Time In Time Out <br /> B`u40 AM <br /> �siness Rep Title QL AM QPM ' 1 � �Q PM <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 /> rz) 0 Active 40 Passenger O'Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 In oor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 Planned 16 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 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 I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 <br /> *.In Compliance-No Violations o <br /> 0 0 Other:§ <br /> z <br /> Comments <br /> u <br /> o� wza <br /> VIC���c•.zr.�L� ar n a f <br /> Inspection Form Included: 0 �57-SZ� Z!�/�i <br /> Comments Included: 0 '&;e' <br /> Business Rep ign ture Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect: E X A M P L 1 2 3 s2os1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br />