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Oa Waste Tire Survey) RA hspec� n Report Inspection Report Number <br /> CalRecycle State of California p 11 - 1255791 <br /> CalRecycle 181(Rev.y(Cal S y rf�1 ey Form — Page <br /> a g e <br /> Dept.of Resources Recycling and Recovery(CalRecycle) !Jd 11 V �J Form�ll C�6`.� <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: �- �- 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier. 50—lel 3 � q V iY1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I C I 1wP j ���1 <br /> Inspection Date <br /> I CA- gs � <br /> Time In Time Out <br /> Business Rep Title �\ T O AM ® AM <br /> �GL LJ v p PM d O PM <br /> '� YICt Operational Status Tire Type . Business Role Storage Type <br /> Tire Count(Whole/PTE) � <br /> f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � ` <br /> ' I& Active 0 Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned (a 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 /> 0 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 /> 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date mM <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 /> 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 Q Other:§ __ z <br /> Comments P t 311 �3�/j- <br /> 8 <br /> Inspection Form �nc <br /> ncluded: Q <br /> Comments luded: Alk <br /> IWI <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS BACK I Correct:0 Incorrect: X a� q I IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />