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ow <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ <br /> caiRecycle State of California 10 0) Survey Form - Page - 1176358 <br /> CalRecycle 181(Rev. /I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey Inspection Details <br /> Inspection Observation <br /> Business Profile sp ctio C <br /> Inspection Type(Fill one) <br /> TPID 0 Referral 0 Observation <br /> Site Suffix: 05 8 0 L ® Routine 0 Re-inspection <br /> If <br /> If Referral,choose referral type(Fill one) 0 Other <br /> Local CECT 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit <br /> 'fi <br /> Site <br /> Inspected By Inspector <br /> Business or Facility Name <br /> Physical Address t <br /> L-2 Inspection Date <br /> CA 1�5A 01-3 Time In 0 AM Time Out 0 AM <br /> Business Rep Title PM 0 PM <br /> VA L-ov kucel C)f 41 operational status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 0 Active 0 Passenger I&Generator 0 Outdoor <br /> 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> GPS Latitude 0 0 Inactive 0 Truck 0 End-Use 0 container <br /> Longitude 0 Planned 0 OTRBusiness Type(Fill all — <br /> at apply) 0 Tire Derived Fuel <br /> 0 New Tire Dealer U Auto Repair ® Trucking Fie 0 <br /> Government _(�Reteader Dismantler <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 REQUIREMENTS 0 Notice of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Compliance Deadline <br /> h Registered Waste Tire Haulers. <br /> Compliance <br /> 'a of Violation 0 Extension <br /> mp ance Deadline <br /> 0 0 PRC§42953-Contracts with <br /> 0 0 PRC§42956-Registration/Decal in Vehicle ts Date <br /> Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459-Responsible Entities <br /> m / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EXT) N <br /> 0 0 <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 0 Referred CalRecycle Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ID In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments —----------------- <br /> inspection Form Included: 0 <br /> g ture Phone Number <br /> s <br /> Comments Included: 0 usin s Rep's Signature Phone Number I is 62081 <br /> ?V E X' M ' E <br /> INSTRUCTIONS ON BA Co Pink Copy: <br /> Correct: Incorrect: W <br /> K <br /> White Copy:CalRecycle Yellow COPY:operator <br />