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a <br /> Waste <br /> Tirefte & Inspection Re op Inspection Report Number <br /> CalRecycle StatofCalifornia <br /> _ ■ <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 I1 1226248 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I i _ I Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC / If Referral,choose referral type(Fill one) <br /> Identifier: J Gln J t�Clq lel l r1 I�uu 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> S DAXS As F i r m <br /> Physical Address Cszob <br /> UAM f/- ecA. <br /> 1 Inspection Date ` / 0 -S / I J, <br /> Time In Time Out <br /> Business Rep Titlep O AM 1 0 AM <br /> "` ® PM I O ® PM <br /> 4 UkUJ n <br /> Operational Status Tin;Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ' I h (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ®Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 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 /> 0 Service Station 0 Hauler ® 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 2 <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ z <br /> Comments 'cls S� if�—U '-"a– , (J�rd <br /> es cklc-us conuin- <br /> Inspection Form Included: 0 K)J <br /> Comments Included: A G <br /> Business Rep's Signature Phone Number Inspe t is Signature Phone Number <br /> �-� <br /> INSTRUCTIONS ON BACK 1c:70rrect:I& Incorrect: X� q( EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />