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Waste Tire Survey & Inspection Re orpinspection Report Number <br /> CalRecycle State of California _ <br /> CalRecycle 181(Rev. y(Cal Survey Form Page 1 I1 1255759 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O � Inspection Type(Fill one) <br /> Site Suffix: 48 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'e70,_rr '3G„ �y v;� ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �+-�1 Inspected By Inspector <br /> �o�S PV'-'-V3 Serv�C� q - C) T 0 <br /> Physical Address <br /> 2 SS 3 3 N• �;�1�t��.y q °� <br /> 0` Inspection Date <br /> ACo'"eo Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 ' 3 0 0 PM (] 0 0 PM <br /> 2�f� G� �►0. C,�alSCe <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / Active Passenger 0 Generator Outdoor <br /> O Q Closed Q Altered <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 /> New Tire Dealer 0 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 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 <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments ,,`` ` 4 „ Q�� <br /> l'� �� � lr�i[1�n �^- (1110N. "l 4.S c rs��, <br /> Inspection Form Included: Q U 3 0-2.1t3 <br /> Comments Included:qp �-� <br /> usiness Rep's Signature Phone Number Ins, tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �Correct:0 incorrect: g IEIXIAIMIPILIEI 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />