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Waste Tire Su. vey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California I 1 - 1210273 <br /> CalRecycle 181(Rev.y H0) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /� - Q d Inspection Type(Fill one) <br /> Site Suffix: V / `[y C (� d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: V & Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> q� <br /> Ph sical Add / c) / �G- I <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title e / 0 0 AM J �f — �"� O AM <br /> Q PM / v v ® PM <br /> vl C/ Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (FII all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> � ® Active ® Passenger &Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Is New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I* 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Notice Of Violation Q Extension <br /> Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 00 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 EXE 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 /> 2 <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 /> Inspection Form �nc <br /> ncluded: 0 <br /> Comments luded: ,7 <br /> Busin p's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE' 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />