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Waste Tire Su. vlll�y & Inspection ReporAlOpection Report Number <br /> CalRecycle State of California _ ■ <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 11 1177842 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 , O Inspection Type(Fill one) <br /> Site Suffix: "L l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �' i If Referral,choose referral type(Fill one) <br /> Identifier: AY) J OC i^ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name CO`^+vl Inspected By Inspector <br /> J �4-on, kc, <br /> Physical Address 3 O <br /> 1 p� Inspection Date <br /> Time In Time Out <br /> Business Rep Title ? O AMO AM <br /> CCA I, ..11 J S 4.PM O 0 PM <br /> 4 f W�v Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> SCJ Q Active Q Pas g r Q Generator Q Outdoor <br /> O 40 Closed Q Altered N/4 ,w <br /> /11 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 4j 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility iiiiENFORCEMENT"'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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7 j N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> Comments n <br /> N©W-- <br /> 41 01Jqpn6 V af,U'S iy)( 'n- <br /> Inspection Form Included: Q �r '-537- <br /> Comments <br /> 537-Comments Included: — S.- -- <br /> Business s Signatur Phone Number Ins ctor's Signaure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE I 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />