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Waste Tire Su,vey & Inspection Repo Anspection Report Number <br /> CalRecycle State of California I <br /> CalRecycle 181(Rev. H1 - 1242217 <br /> o) Survey Form - Page 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: -7L{ 3 'A ' ( ,® Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sC"V\ JcC;fC(,'AN% ��vwt.., Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �v! Inspected By Inspector <br /> ' z <br /> Physical Address V C� - 1 t t� r� ,n_,m <br /> Inspection Date / <br /> ( ( Time In Time Out <br /> Business Rep Title ®AM O AM <br /> 1 ( • :2, 5 OPM L 2- : U GPM <br /> c-'YX X61 s'Ne.C'c <br /> 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 Passenger 9 Generator Q Outdoor <br /> o Q Closed ® Altered <br /> GPS Latitude Q Hauler 40 Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned 40 OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> QP New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 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 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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments ` <br /> Inspection Form Included: 0 <br /> Comments Included: ® &La q y 7 <br /> /0siness Rep's Signa re Phone Number n e or's nat re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: _ � NJ E I X M 112' 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />