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Waste Tire Su. vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — ■ <br /> CalRecycle 181(Rev. (Cal. Survey Form - Page 1 I1 1229945 <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� (� � � � _ � ` Inspection Type(Fill one) <br /> Site Suffix: } I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� n (; COW\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name( -4--If�+ Inspected By Inspector <br /> Rld`ress "' W�d �- ��S �C �/ I - 1 0 I M Al � V <br /> Physa <br /> Item <br /> Inspection Date c� Z <br /> 1L Time In Time Out <br /> Business Rep Title 1 0 AM0 AM <br /> ' L o 0 PM � O 6 *PM <br /> �� %0_s, 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 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler , Indoor <br /> O 0 Inactive 40 Truck <br /> Longitude - 0 Planned 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 40 Other ..Dl— <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - � 0 Notice Of Violation � Extension <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 I <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 ®In Compliance-No Violations o <br /> Q 1 O 1 Other:§ <br /> i <br /> Comments <br /> 1 0-hems nr ArectSy!� Cckref <br /> Inspection Form Included: 0 w <br /> Comments Included:VW <br /> I Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIO CK orrect:0 Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />