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Waste Tire S'u,vey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California �1 _ <br /> CalRecycle 181(Rev.y(Ca) S Ii vee F®rff�fY _ page 1 g 1242189 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey� Y �J If 1� <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: / k� vL It ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l Sa If Referral,choose referral type(Fill one) <br /> Identifier: �`I" �� �YL 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 0al9'tPl'i.@ r _ 1 J � , <br /> Physical AddressI "� �L. — <br /> j ,�^ Inspection Date -7 <br /> ' "�� ` �� (� Time In Time Out I <br /> Business RepT'ue 0) AM (�AM <br /> �j O PM I 0 PM <br /> 4c-Me <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 (ft Passenger a Generator 0 Outdoor <br /> O 0 Closed 0 Altered OV//+ <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o _ . <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 ® Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 EXn <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> In Compliance-No Violations o <br /> 0 1 0 1 Other:§ - - <br /> Comments <br /> � r <br /> Inspection Form Included: 0 c �f <br /> Comments Included: � -/ / • 3 <br /> Business R one Number InjpeAtor' 1cjAature Phone Number <br /> INSTRUCTIONSON BACK [Correct: Incorrect: � E X A L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop ® ■ <br />