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rMA <br /> 2 Waste Tire Wey & Inspection Repoi Inspection Report Number Ilimm <br /> IL <br /> CalRecycle State of California 11 - 1226273 <br /> CalRecycle 181(Rev. (CaRecycle) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(Cal <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: ® Routine O Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cq\�A O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cie <br /> Physical ddre s/ 7Krf S Q <br /> !7 / 90,6�e n F jrAj <br /> Inspection Date s- <br /> / r Time In Time Out <br /> Business Rep Title O AM Q AM <br /> v ® PM © 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 /> ® Active Q Passenger ® Generator 10 Outdoor <br /> GPS Latitude o 0 Closed 0 Altered O Hauler ® Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q 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 - 1 <br /> 1 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 1 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 Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> QCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations <br /> Q Other: <br /> Comments N <br /> llut�c��t�✓cc�---�c�1�r1 <br /> Inspection Form Included: O <br /> Comments Included: ® - lzTy�a-l�GL <br /> Business R #'sSignature Phone Number Inspectoes Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: � ( � E X A M P L Ej 1112F3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />