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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1242195 <br /> CalRecycle 181(Rev.1 (Cal .Survey Form � age <br /> Dept of Resources Recycling and Recovery(CalRecycle) v � M ��tl y�i <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: y 3 1 � 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �• If Referral,choose referral type(Fill one) <br /> Identifier: c_ `/L ���. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> L W - <br /> Physical Address ;; ``� AA <br /> .���'pit E : 1,-�t�,vvti vri.�y' L✓� <br /> Cy �j Inspection Date <br /> `�"•"' c-a` l Time In Time Out l / <br /> Business Rep Title ®AM O AM <br /> i Q Q PM t C� ®PM <br /> v L 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 /> 4V Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GpS Latitude Q Hauler Q Indoor <br /> O Q Inactive a Truck <br /> Longitude - Q Planned Q OTR ® End-Use ® Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q 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 Q - �Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 1 1 <br /> § <br /> Q Q 14 CCR 18459.1 -Tire Program ID Number from CalRecycle l <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> • Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments ` <br /> _S w wt <br /> Inspection Form Included: Q <br /> Comments Included: ® `f��/�2 <br /> Business Rep's Signature Phone Number I pe or's gn ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: XA � EXAMPLE1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />