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Oa Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — <br /> Y CalRecycle 181(Rev.y(Ca[ Survey Form - Page 1 I1 1196670 <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� 3 � _ O � Inspection Type(Fill one) <br /> � � <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �t^ co <br /> v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Kaw.S k' -o <br /> Physical Address <br /> Inspection Date / 0 3 <br /> �CkOY c1� �s2IS <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 5avv� 1 3 ® 0 PM ' 0 PM <br /> Bc C'Vr\' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger I* Generator 0 Outdoor <br /> 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 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 /> 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 1 Q 1 Other:§ <br /> Comments <br /> ��0� )nyre_ C'a'n <br /> e,, S <br /> Inspection Form Included: Q <br /> Comments Included: <br /> _ Business R p's Sig atur Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* In orrect: ? EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />