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Waste Tire c. vey & Inspection Repoi Inspection Report Number <br /> CalRecycle State of California I 1 _ 11 6 9 <br /> CalRecycle 181(Rev. H0) Survey Form - Page 1 r I <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: 1^� l 5 6 ir 3 j ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local e. If Referral,choose referral type(Fill one) <br /> Identifier: zx�a ' xaqjU, YN CC) 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 2r', (.�nd�✓ _ V 1l <br /> Inspection Date � / <br /> CA 5�0� Time In Time Out l <br /> Business Rep Title ,� ® AM ®AM <br /> C) <br /> � .V l 5 QPM 0 -1 0P <br /> L Gt en - 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 /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> 0 0 Closed 0 Altere Al/A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 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 /> e 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 /> 0 0 Other:§ <br /> Comments <br /> ,S (rem W <br /> em <br /> Inspection Form Included: 0 <br /> Comments Included. I �✓y ? <br /> Business Rep's Signature Phone Number Ins t ig t e Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: X � V EXAM 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />