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Waste Tire ° vey & Inspection ReporeInspection <br /> �lR�e7p/o'rt Number ■ <br /> CalRecycle State of California 1 _ 11 / h 5 7 /I. <br /> CalRecycle 181(Rev. y(Cal Survey Form - Page 1 1 lJ �. "E <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: Li 4 ) G ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,u j Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> se-kc'_r Ju S}c�•,� S <br /> Physical Address 3 - l ! �t 'aced' <br /> I Z S G� ��'r mc;�v� S} • i <br /> ,1 Inspection Date Q / 3 d / f <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> s+� 3 5 ® PM I S * pm <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (�j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 7' ® ActiveQ Passenger g ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) N)A <br /> Q New Tire Dealer Q Auto Repair Q 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 ® Other �1crs c + t X `�um� C_ <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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M <br /> / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/'CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> - -- <br /> Comments <br /> �W-CA-f Yl o 4cCl — <br /> Inspection Form Included: t� <br /> Comments Included:. <br /> Busines Rep's Signature Phone.Number spector's Signature. Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X AA L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE <br />